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DISEASES 


OF   THE 


Genito-Urinary  Organs 


AND 


THE    KIDNEY 


BY 

ROBERT    HOLMES    GREENE,  A.M.,  M.D. 

PROFESSOR   OF    GENITO-URINARY    SURGERY,    MEDICAL  DEPARTMENT   OF   FORDHAM    UNIVERSITY; 
GENITO-URINARY  SURGEON  TO   THE  CITY  AND    TO   THE   FRENCH  HOSPITAL, 
NEW   YORK   city;    FELLOW   OF   THE   AMERICAN  ASSOCIA- 
TION OF  GENITO-URINARY  SURGEONS 


AND 

HARLOW    BROOKS,  M.D. 

PROFESSOR  OF  CLINICAL  MEDICINi:,   UNIVERSITY  AND  BELLEVUE  HOSPITAL  MEDICAL  SCHOOL; 

VISITING    PHYSICIAN    TO    THE    CITY    HOSPITAL    AND    TO    THE    MONTEFIORE    HOME    FOR 

CHRONIC     INVALIDS,     NEW     YORK     CITY;       CONSULTING      PATHOLOGIST     TO     THE 

MUHLENBERG  HOSPITAL,  PLAINFLELD,  AND  TO  THE  HACKENSACK  HOSPITAL, 

N.    J.;     CONSULTING   PHYSICIAN   TO   THE    BETH   ISRAEL    AND    TO    THE 

UNION  HOSPITALS,  NEW  YORK;    TO  THE  ST.  MARY's  HOSPITAL, 

HOBOKEN;    TO    THE    GREENWICH  HOSPITAL,  AND    TO   THE 

NEW  LONDON    MEMORIAL  HOSPITAL,  CONN. 


FOURTH  EDITION,   THOROUGHLY  REVISED 


PHILADELPHIA   AND   LONDON 

W.  B.  SAUNDERS  COMPANY 

1917 


Copyright,  igoy,    by  W.  B.  Saunders  Company.       Revised,    reprinted,    and    recopy- 
righted    September,    igo8.      Revised,    reprinted,    and    recopyrighted 
January,  1912.     Revised,  reprinted,  and    recopy- 
righted April,  1917 


Copyright,  1917,  by  W.  B.  Saunders  Company 


PRINTED    IN    A.I1IERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 
PHILADELPHIA 


THIS  BOOK  IS    DEDICATED 
TO 

Hemuel  Bolton  Banas,  flD.  'B. 

AS  A  TRIBUTE   OF    RESPECT    FOR   HIS    RESEARCHES   IN 

GENITO-URINARY  surgery  AND  FOR  THt  HIGH 

STANDARD  HE  HAS  ALWAYS  MAINTAINED 

AS  A  MEMBER  OF   THE   MEDICAL 

PROFESSION 


PREFACE  TO   THE   FOURTH   EDITION 


The  demand  for  a  fourth  edition  has  caused  the  authors  to 
feel  deeply  their  sense  of  responsibility  to  their  readers.  The 
fact  that  more  knowledge  is  being  accumulated  as  to  the  nature 
and  treatment  of  malignant  growths  in  the  urinary  tract  and 
to  other  diseased  conditions  of  the  kidney,  but  is  not  as  yet 
fully  cr}''stallized,  has  made  the  task  a  difficult  one  in  choosing 
the  new  material  for  this  work.  We  have  endeavored  as  much 
as  possible,  without  overburdening  the  text,  to  give  the  result 
of  our  own  experience  and  to  avoid  as  far  as  possible  specula- 
tive views,  thus  endeavoring  to  make  the  book  of  practical 
utility  and  to  base  our  theory  and  practice  on  a  sound  patho- 
logic and  physiologic  basis. 

Robert  Holmes  Greene. 

Harlow  Brooks. 
78  East  56th  Street, 

New  York  City,  April,  191 7. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofgenitoOOgree 


PREFACE 


It  has  been  the  purpose  of  the  writers  to  present  in  this 
volume  a  discussion  of  the  more  important  disease  conditions  of 
the  uro-genital  tract,  taken  from  the  standpoint  of  the  general 
practitioner  and  surgeon.  In  so  far  as  possible  they  have  at- 
tempted to  incorporate  such  methods  as  they  personally  have 
found  most  practical  and  useful,  all  of  which  they  believe  may 
be  successfully  employed  in  the  hands  of  any  well  equipped  prac- 
titioner, familiar  with  modern  medical  and  surgical  technic. 

The  writers  do  not  profess  that  the  book  is  complete;  this 
would  be  impossible  in  a  work  of  this  size.  They  have  attempted 
to  devote  the  greatest  amount  of  space  and  the  fullest  descrip- 
tions to  those  conditions  and  methods  which  have  appeared  to 
them  to  be  of  the  greatest  importance,  or  to  those  which,  being 
of  recent  development,  may  be  presumed  to  be  less  familiar  to 
the  practitioner. 

A  larger  amount  of  space  has  been  devoted  to  the  urinary 
organs  proper,  and  relatively  less  has  been  said  of  purely  sexual 
disorders. 

The  work  is  the  conjoint  product  of  a  surgeon  and  a  physician, 
and  it  is  intended  that  equal  attention  should  be  devoted  to  both 
medical  and  surgical  aspects  of  these  diseases. 

References  to  literature  have  not  been  exhaustively  made. 
So  many  suggestions  of  value  have,  however,  been  found  in  the 
work  of  Berger  and  Hartmann  and  in  that  of  Frisch  and  Zucker- 
kandl  that  they  require  especial  mention  in  this  preface. 

Robert  Holmes  Greene. 
Harlow  Brooks. 


CONTENTS 


CHAPTER  I 

PAGE 

General  Examination  of  Patients 17 

The  Instrumental  Examination 32 

Catheterization 43 

The  Value  of  the  X-ray  in  Diagnosis 51 

CHAPTER  II 

Endoscopy. — Cystoscopy. — Catheterization  of  the  Ureters 56 

Endoscopy 56 

Cystoscopy 60 

Instrumental  Examination  of  the  Kidney 70 

Catheterization  of  the  Ureters 70 

IMethods  of  Separating  the  Urine  from  Each  Kidney  without 

Catheterizing  the  Ureters 79 

Tests  Showing  the  Permeability  of  the  Kidney 80 

Test  Showing  Permeability  of  the  Kidney  Associated  with  Ureter 

Catheterization 86 

CHAPTER  III 

The   Care   of   Urethral   Instruments. — Preparation   of   Patient 

FOR  Operation  akd  After-care 90 

The  Care  of  Urethral  Instruments 90 

Preparation  of  Patient  for  Operation 96 

CHAPTER  IV 

Examination  of  the  Urine  and  Urethral  Exltjate 112 

Examination  of  the  Urine 112 

Urinar>'  Constituents 114 

Ivlicroscopic  Examination  of  the  Urine 119 

Organized  Deposits 120 

Crystalline  Deposits 125 

Bacteria 127 

Examination  of  the  Urethral  Exudate 128 

Examination  of  the  Seminal  Secretion 139 

Examination  of  Secretions  and  Exudates  from  the  Female  Geni- 
tals    142 

Examination  for  the  Spirochseta  Pallida 144 

CHAPTER  V 

The  Kidney 147 

Embrj'ology i47 

Anatomy 148 

Physiology i54 

Compensation  in  Renal  Disease 158 

CHAPTER  VI 

The  Blood  in  Diseases  of  the  Kidney 163 

Blood-pressure  in  Renal  Disease 170 

13 


14  CONTENTS 

CHAPTER  VII 

PAGE 

The  Ocular  Manifestations  of  Renal  Diseases 175 

CHAPTER  Vni 

The  Kidney  in  Acute  Infectious  Diseases. — Suppurative  Nephritis  179 

The  Kidney  in  Acute  Infectious  Diseases 179 

Suppurative  Nephritis 184 

CHAPTER  IX 

Bright's  Disease 194 

Pathology 1 94 

Symptoms,  Diagnosis,  Course,  and  Prognosis 206 

Treatment 212 

CHAPTER  X 

Uremia 223 

CHAPTER  XI 

Tuberculosis  of  the  Kidney. — The  Kidney  in  Syphilis 237 

Tuberculosis  of  the  Kidney 237 

The  Kidney  in  Syphilis 244 

CHAPTER  XII 

Malformations  and  Displacements  of  the  Kidney 247 

Congenital  Malformations 247 

Movable  and  Floating  Kidney 250 

Hydronephrosis 253 

CHAPTER  XIII 

Wounds  and  Injuries  of  the  Kidney 261 

Wounds 261 

Injuries • 268 

CHAPTER  XIV 

Renal  Calculus 268 

CHAPTER  XV 

Tumors  of  the  Kidney 277 

Diagnosis 283 

General  Considerations  and  Treatment 285 

CHAPTER  XVI 

The  Surgery  of  the  Kidney 288 

Operations  for  the  Exploration  of  the  Kidney 291 

Nephropexy' 294 

Nephrotomj^ 299 

Nephrectomj' 303 

Decapsulation  of  the  Kidney 315 

Surgicial  Treatment  of  Bright's  Disease 316 

Lavage  of  the  Pelvis  of  the  Kidney 318 

CHAPTER  XVII 

Anatomy,  Physiology,  and  Pathologic  Anatomy  of  the  Ureters,  .  .  320 


CONTENTS  1 5 
CHAPTER  XVIII 

PAGE 

Surgery  of  the  Ureters  and  for  the  Relief  of  Hydronephrosis.  .  327 

CHAPTER  XIX 

Anatomy,  Physiology,  and  Pathology  of  the  Bladder 343 

CHAPTER  XX 

Diagnosis  and  Treatment  of  Diseases  of  the  Bladder 355 

Cystitis 356 

Stone  in  the  Bladder 364 

Litholapaxy •. 368 

Curettage  of  the  Bladder 375 

Suprapubic  Cystotomy 376 

Cystostomy 385 

Treatment  of  Bladder  Tumors 388 

Exstroph}^  of  the  Bladder 397 

Injuries  of  the  Bladder 404 

Rupture  of  the  Bladder 405 

Total  Extirpation  of  Bladder 407 

Hernia  of  the  Bladder , 408 

Diverticula  of  Bladder 410 

CHAPTER  XXI 

The  Anatomy  of  the  Penis  and  Male  Urethra 412 

CHAPTER  XXII 

Diseases  of  the  Male  Urethra 417 

Urethritis 4^7 

Sj'mptoms 422 

Diagnosis 424 

Treatment  of  Non-gonorrheal  Urethritis 427 

Abortive  Treatment 428 

Treatment  of  Acute  Anterior  Urethritis 430 

Treatment  of  Chronic  Anterior  Urethritis 435 

Treatment  of  Acute  Posterior  Urethritis 438 

Treatment  of  Chronic  Posterior  Urethritis 438 

Resume  of  the  Treatment  of  Urethritis 44° 

Complications •  •  44^ 

Stricture  of  the  Meatus  in 453 

Strictiu-e  of  the  Urethra  in 454 

Treatment  for  Retention  of  Urine  and  of  Tight,   Impassable 

Stricture 459 

Rupture  of  the  Urethra 47^ 

Abscess  of  Cowper's  Glands 474 

Resection  of  the  Urethra 47^ 

Operations  for  the  Relief  of  Urethral  Fistula 479 

CHAPTER  XXIII 

The  Female  Urethra 487 

Anatomy 487 

Congenital  Malformations 488 

Examination  of  the  Female  Urethra 489 

Stricture  of  the  Female  Urethra 49° 

Dilation  of  the  Urethra 49i 

Urethral  Fissure 49^ 

Peri-mrethral  Abscess 492 

Urethritis 492 

Tumors 494 


1 6  CONTENTS 

CHAPTER  XXIV  PAGE 

The  Penis 497 

Injuries 497 

Growths  and  Ulcerations 499 

Foreign  Bodies  and  Calculi  in  the  Urethra 501 

Hypospadias 502 

Epispadias 507 

Amputation  of  the  Penis 509 

Phimosis 514 

Paraphimosis 515 

Circumcision 516 

CHAPTER  XXV 
The  Seminal  Vesicles 522 

CHAPTER  XXVI 

Anatomy,  Physiology,  and  Pathology  of  the  Prostate  Gland  .  . .  532 

Anatomy' 532 

Physiology 533 

Congenital  Defects 533 

Injuries 534 

Hyperemia 535 

Prostatitis 535 

Hypertrophy 537 

CHAPTER  XXVII 

Diagnosis  and  Treatment  of  Diseases  of  the  Prostate 546 

Acute  Prostatitis 546 

Chronic  Prostatitis 547 

Abscess  of  the  Prostate 557 

Prostatic  Calculi 559 

Prostatic  Hypertrophy 560 

Removal  of  the  Prostate  through  a  Suprapubic  Opening 574 

Tumors  of  the  Prostate 587 

CHAPTER  XXVIII 

Anatomy  and  Pathology  of  the  Testicle  and  Epididymis 596 

Anatomy 596 

Pathology 599 

Elephantiasis  of  the  Scrotum 613 

CHAPTER  XXIX 

The  Treatment  of  Diseases  of  the  Testicle  and  Epididymis.  . .  .  617 

Therapeutic  Measures 617 

Surgery  of  the  Testicle  and  Its  Covering 621 

Operation  for  Hydrocele 62 1 

Epididymectomy 627 

Castration 628 

Treatment  for  Inguinal  Retention  of  the  Testicle 63 1 

Treatment  of  Atrophy  of  the  Testicle 634 

Treatment  of  Injuries  to  the  Testicle 634 

The  Treatment  of  Varicocele 635 

The  Treatment  of  Tumors  of  the  Testicle 637 

Irrigation  and  Drainage  of  the  Seminal  Duct  and  Vesicle  through 

the  Vas  Deferens 637 

Treatment  of  Elephantiasis 639 

CHAPTER  XXX 
Neuroses  of  the  Sexual  Organs 640 

Index 649 


DISEASES  OF  THE 

Genito-urinary  Organs  and  Kidney 


CHAPTER  I 

GENERAL  EXAMINATION  OF  PATIENTS 

The  methods  of  examining  patients  who  are  beUeved  to  be  suf- 
fering from  lesions  of  the  urinary  tract  are  so  diverse  that  the  in- 
sertion of  a  chapter  devoted  to  the  discussion  of  these  methods 
has  seemed  desirable.  Undoubtedly  much  that  appears  here  is 
already  so  well  known  as  hardly  to  require  mention.  It  is  hoped, 
nevertheless,  that  those  to  whom  the  treatment  of  urinary  disease 
is  comparatively  new  work  will  find  its  perusal  helpful.  In  our 
experience,  errors  in  diagnosis  are  most  often  due  to  neglect  in 
following  a  systematic  method  of  examination. 

The  art  of  questioning  the  patients  and  of  carefully  interpreting 
the  answers  plays  so  important  a  part  in  the  formation  of  a  correct 
diagnosis  in  urinary  diseases  that  it  is  well  to  cultivate  a  definite 
method  in  this  division  of  diagnostic  work. 

A  good  plan  to  follow,  after  eliciting  the  necessary  information 
regarding  the  family  and  personal  history,  is  to  question  the  pa- 
tient concerning  the  symptoms  complained  of  in  the  upper  extrem- 
ities, and  so  to  continue  on  down  the  body  to  the  soles  of  the  feet. 
Although  in  a-  few  cases,  as  for  instance,  that  of  a  young  man 
with  a  primary  acute  urethritis,  it  would  be  an  unnecessary  waste 
of  time  to  go  into  the  usual  questions  concerning  the  family  his- 
tory, diseases  of  childhood,  and  habits  of  Hfe,  still,  in  the  majority 
of  cases,  a  correct  diagnosis  can  be  made  only  after  a  thorough 
examination — both  objective  and  subjective. 

General  questions  should  bear  upon  the  family  history.  The 
cause  of  death  of  the  various  members  of  the  patient's  family 
should  be  ascertained,  and  the  important  subject  of  hereditar\ 
tendencies  should  receive  full  consideration.  In  this  way  a  gouty 
diathesis,  a  tendency  toward  nerve  derangements  and  toward  early 

2  17 


1 8  GENERAL    EXAMINATION    OF   PATIENTS 

arteriosclerosis,  may  be  traced.  Diseases  of  the  nervous  system 
are  increasing  at  an  alarming  rate,  hence  information  concerning 
hereditary  tendencies  toward  the  acquirement  of  nerve  derange- 
ments are  particularly  significant  in  this  connection  when  we 
remember  how  close  a  relationship  exists  between  the  condition 
of  the  nervous  system  and  that  of  the  urinary  tract.  Diseases  of 
the  former  may  give  rise  to  functional  diseased  conditions  of  the 
kidney,  the  urethra,  the  bladder,  the  prostate,  and  the  sexual  ap- 
paratus. Certainly  so  far  as  the  kidneys  are  concerned,  and  prob- 
ably also  to  some  extent  with  the  other  organs  mentioned,  nerve 
derangement  may  even  be  the  direct  cause  of  organic  changes  in 
them.  Questions  regarding  a  tendency  toward  early  arterioscle- 
rosis are  of  equal  significance,  certain  American  families  displaying 
an  astonishing  leaning  jn  succeeding  generations  to  suffer  from 
progressive  changes  in  the  arteries,  such  as  cause  apoplexy  and 
various  forms  of  paralysis.  This  is  particularly  noticeable  among 
the  wealthy,  and  seems  to  indicate  that  luxurious  habits  tend  to 
produce  early  changes  in  the  arterial  system,  whereas  excessive 
nerve  strain  may  give  rise  to  some  renal  condition,  such  as  inter- 
stitial nephritis,  and  thereby  shorten  the  life  of  the  individual. 

Recent  studies  have  shown  beyond  doubt  that  there  is  a  very 
definite  familial  tendency  in  certain  types  of  renal  disease  and 
particularly  in  chronic  hypertensive  nephritis. 

Mendelism.- — The  rediscovery  of  the  work  done  by  Gregor 
Mendel,  published  in  "Mendel's  Principles  of  Heredity,"  by  W. 
Bateson,  M.  A.,  F.  R.  S.,  V.  M.  H.,  1913,  of  certain  laws  governing 
the  production  of  plants,  and  inferences  drawn  from  the  observa- 
tion of  rat  tumors  as  handed  down  from  one  generation  to  another, 
has  stimulated  work  on  the  question  of  heredity,  particularly  as 
applied  to  malignant  tumors.  Definite  knowledge  of  nature's 
laws  in  this  respect  has  not  yet  been  worked  out,  but  enough  has 
already  been  discovered  to  make  the  subject  one  of  great  interest 
and  to  emphasize  the  necessity  of  the  utmost  care  being  used  in 
obtaining  correct  family  histories  for  as  many  generations  back  as 
possible. 

This  matter  will  be  referred  to  later  in  the  discussion  of  malignant 
growths  of  the  urinary  tract,  but  is  of  so  much  importance  that  it 
should  be  noted  here. 


GENERAL   EXAMINATION    OF   PATIENTS  I9 

Personal  questions  can  not  be  gone  into  too  exhaustively,  and 
it  is  well  to  have  some  definite  plan  that  Avill  insure  against  any 
important  symptom  being  overlooked.  The  practitioner  must  be 
prepared  here  to  meet  a  certain  amount  of  obtuseness,  for  even 
individuals  apparently  well  equipped  mentally  sometimes  show  an 
inability  to  answer  intelligenth^  the  simplest  questions  concerning 
their  past  or  present  symptoms.  In  these  cases,  where  the  patient 
is  suffering  from  some  obscure  conditions,  long  and  patient  ques- 
tioning may  be  necessary. 

Interrogate  first  regarding  the  presence  of  headache  in  its  va- 
rious forms — frontal  headache,  for  instance,  if  not  due  to  a  diseased 
condition  of  the  air-passages,  is  often  associated  with  kidney 
lesions  or  perhaps  with  some  chronic  infectious  or  toxic  process 
originating  in  the  prostate,  seminal  vesicles,  or  elsewhere.  Next 
inquire  into  the  condition  of  the  hair,  and  the  acuteness  of  sight, 
hearing,  taste,  and  smell.  Ascertain  also  the  condition  of  the 
throat,  and  inquire  as  to  pain  in  the  chest  and  shoulders,  pain 
in  the  back,  shortness  of  breath,  and  palpitation  of  the  heart. 
Questions  concerning  the  condition  of  the  stomach  and  the  diges- 
tion in  general  may  elicit  valuable  information.  Concerning 
pain  in  the  abdomen  or  back,  mere  local  pain,  such  as  the  well- 
known  kidney  colic,  the  pain  extending  along  the  course  of  the 
ureter,  is  generally  due  to  calculus.  In  addition  to  this  typical 
renal  colic,  it  should  be  remembered  that  other  diseased  conditions 
of  the  kidney  give  rise  to  pain,  which  may  start  in  the  region  of 
that  organ  and  follow  the  course  of  the  ureter.  Diseased  con- 
ditions of  the  kidney  may  give  rise  to  pain  in  the  lower  extremities, 
and  very  frequently  in  the  lumbar  region.  The  most  common 
type  is  the  ordinary  backache;  this  latter,  however,  is  not  diag- 
nostic of  diseased  kidneys,  and  is  very  likely  to  be  confused  with 
some  diseased  condition  occurring  in  the  sacro-iliac  synchon- 
drosis. Zuckerkandl  believes  that  a  continuous  pain  in  the  kid- 
ney which  is  increased  by  pressure  and  is  accompanied  by  sep- 
sis, endocarditis,  or  myocarditis,  associated  with  the  passage  of 
bloody  urine,  would  warrant  the  diagnosis  of  kidney  infarct. 
Pain  in  the  kidney  is  generally  believed  to  be  relieved  by  rest 
in  a  horizontal  position,  whereas  standing  or  moving  about  is 
said  to  increase  it.     This,  however,  is  true  not  only  of  kidney 


20  GENERAL   EXAMINATION   OF   PATIENTS 

disorders,  but  is  equally  true  of  pain  emanating  from  the  kidney 
region  due  to  disturbance  of  other  organs  or  to  certain  forms  of 
myalgia.  Pain  in  the  kidney  is  at  times  an  indication  of  tubercu- 
losis of  the  kidney,  and  when  associated  with  blood  in  the  urine  is 
quite  suggestive  of  this  affection  if  otherwise  unaccounted  for. 

The  condition  of  the  bowel  should  be  definitely  ascertained — 
whether  there  is  constipation,  whether  defecation  is  accompanied 
by  pain  in  the  prostatic  region,  whether  a  discharge  from  the 
urethra  occurs  during  defecation,  and  whether  or  not  there  is 
pain  in  the  rectum. 

Ascertain  whether  or  not  any  present  or  past  acute  urethral  dis- 
charge has  been  observed;  whether  pus  is  discharging  from  the 
urethra  during  the  intervals  of  urination;  whether  a  shght  dis- 
charge appears  with  the  first  urine  passed;  whether  there  is  a 
discharge  of  a  thin,  milky  character  following  urination  or  defe- 
cation. A  considerable  amount  of  pus  discharging  between 
intervals  of  urination  is  generally  due  to  acute  urethritis.  It  may 
come  from  an  abscess  of  the  prostate  or  from  an  abscess  of  the 
perineal  tissues.  The  same  is  true  of  any  considerable  amount  of 
pus  discharged  at  the  beginning  of  urination.  Discharges  from 
the  urethra  following  urination  or  defecation  may  be  due  to  in- 
creased secretion  from  the  urethral  glands  or  to  spermatorrhea, 
phosphaturia,  or  prostatorrhea.  Shreds  in  the  urine  may  be  due 
to  a  previous  urethritis  or  prostatitis.  Discharges  from  the 
urethra  may  also  be  due  to  tuberculosis,  and  very  rarely  to  a 
syphilitic  involvement  of  the  urethra,  such  as  chancre.  During 
pneumonia,  rheumatic  attacks,  typhoid  fever,  or  other  infectious 
diseases  pus  may  be  excreted  from  the  urethra.  In  the  case  of 
hematuria  due  to  urethral  lesions,  we  are  inclined  to  believe  that  it 
will  appear  only  in  urethras  that  have  been  damaged,  perhaps  years 
before,  by  some  acute  inflammatory  condition,  such  as  gonorrhea. 
Regarding  tuberculosis  as  a  cause  of  purulent  urethral  discharge, 
we  hold  a  similar  view,  for  it  seems  to  be  well  established  that  an 
antecedent  gonorrhea  predisposes  to  a  subsequent  tubercular 
infection. 

Next,  all  possible  information  concerning  micturition  should  be 
elicited.  The  force  of  the  stream;  whether  or  not  pain  is  present 
during  or  after  urination;  whether  the  stream  is  interrupted  or 


GENERAL   EXAMINATION    OF    PATIENTS  21 

suddenly  checked,  should  all  be  inquired  into,  the  answers  to  these 
questions  bearing  upon  a  diseased  prostatic  condition  or  stone  in 
the  bladder.  Increased  frequency  of  urination  is  a  symptom 
in  a  large  variety  of  conditions;  it  may  point  to  diabetes,  to  in- 
creased ingestion  of  fluid,  to  polyuria  (from  some  cause),  to  various 
forms  of  gravel,  to  disease  in  the  upper  urinary  passages,  to  the 
influences  of  heat  and  cold,  and  to  reflex  irritation  (in  both  men 
and  women)  from  diseases  of  the  neighboring  organs.  In  yoimg 
men  it  generally  indicates  some  disease  of  the  urethra;  in  the 
elderly,  as  is  well  known,  it  points  to  diseases  of  the  bladder  or 
prostate. 

A  diminished  amount  of  urinary  excretion  or  diminution  in  the 
frequency  of  its  elimination  may  be  due  to  an  unusually  small  in- 
gestion of  fluid  or  to  excessive  perspiration  or  diarrhea,  as  well  as 
to  circulatory  or  real  renal  defects.  The  smallest  amounts  that  we 
have  observed  passed  by  healthy  subjects  have  occurred  in  cooks, 
stokers,  and  others  whose  occupation  subjected  them  to  prolonged 
exposure  to  heat,  and  who  did  not  counterbalance  the  excessive  • 
perspiration  by  the  ingestion  of  a  proper  amount  of  fluid.  Zuck- 
erkandl  considers  stricture  and  enlarged  prostate  as  occasional 
causes  of  this  condition;  we  believe  that  whereas  they  may  occa- 
sionally be  a  cause  of  infrequent  urination,  the  converse  is  more 
often  true.  Tabes  and  other  disturbances  of  the  spinal  cord 
are  also  possible  causes.  The  habit  of  many,  particularly  of 
women  employed  in  manufacturing  estabUshments,  of  refraining, 
for  as  long  a  time  as  possible,  from  answering  nature's  demand 
for  the  performance  of  this  physiologic  function  is  a  common 
cause  of  this  condition.  It  is  unfortunately  too  true  that  proper 
accommodations  are  not  always  afforded  to  the  employed,  and 
that  a  sense  of  delicacy  often  acts  as  a  factor.  Continued  over- 
distention  of  the  bladder  may  later  lead  to  the  development  of 
cystitis,  and  this  may  explain  the  reason  why  women  are  more 
often  affected  with  cystitis  than  men. 

Whether  there  has  been  a  change  in  the  caliber  of  the  stream 
should  be  ascertained,  although  a  correct  conclusion  can  rarely  be 
reached  in  this  way.  Change  in  caliber  from  the  normal  is  ordi- 
narily due  to  diseases  of  the  urethra,  such  as  stricture,  which  may 
lead  to  the  ejection  of  a  crooked  or  a  forked  stream.     Diseases  of 


22  GENERAL   EXAMINATION   OF   PATIENTS 

the  prostate,  nervous  system,  or  bladder-walls  may,  however,  give 
rise  to  a  mere  dribbling  of  urine.  Here  it  may  be  well  to  mention 
that  the  careful  anatomic  investigations  carried  on  by  Ciechanow- 
ski  on  the  amount  of  muscular  tissue  in  the  bladder-walls  in 
healthy  individuals  show  that  in  the  aged  there  is  a  lessening  in  the 
amount  of  normal  bladder  muscle  tissue;  that  in  old  men, 
as  shown  by  accurate  measurements,  only  about  two-thirds  of 
the  amount  of  muscular  tissue  present  in  healthy  adults  exists. 
In  children  a  long  tight  foreskin  causes  greater  diminution  in  the 
caliber  of  the  stream;  in  adults,  increase  in  size  of  the  meatus 
affects  the  caliber  of  the  urinary  stream.  The  force  is  also  depen- 
dent, to  a  great  extent,  upon  the  condition  of  the  nerves  and  mus- 
cles of  the  bladder  and  urethra,  and  upon  the  presence  or  absence 
of  urethral  obstruction.  When  the  stream  is  suddenly  completely 
checked,  only  to  start  again  at  full  caliber,  stone  in  the  bladder 
is  generally  indicated.  If  prostatic  obstruction  exists,  the  stop- 
page is  more  gradual,  ending  in  a  sort  of  dribbling.  Other  bladder 
lesions  besides  stone  may  probably  give  rise  to  sudden  stoppage 
of  the  flow.  It  has  been  observed  in  old  men  the  trabeculae  of 
whose  bladders  were  thickened  and  in  whom  repeated  examina- 
tions failed  to  elicit  the  presence  of  stone. 

The  question  as  to  whether  or  not  pain  accompanies  urination 
may  not  furnish  much  information,  owing  to  the  marked  dif- 
ferences regarding  sensitiveness  to  pain  that  exists  between  various 
individuals.  Those  suffering  from  neurasthenia  or  hyperesthesia 
of  the  deep  urethra  may  complain  of  painful  micturition ;  whereas 
those  suffering  from  marked  organic  disturbance  in  the  urethral 
canal  may  not.  Some  writers  believe  that  pain  occurring  at 
the  beginning  of  urination  indicates  disease  of  the  urethra  and 
prostate,  and  that  pain  at  the  end  indicates  disease  of  the  bladder. 
Pain  in  the  bladder  between  the  acts  of  urination  may  indi- 
cate stone,  tumors,  or  pus-formation  in  the  prostate.  Concen- 
trated urine  and  the  passage  of  gravel,  as  is  well  known,  will  give 
rise  to  pain  and  disease  of  the  bladder.  Pain  is  most  prolonged 
and  marked  in  the  bladder  region  in  acute  cystitis,  which  may 
be  associated  with  tuberculosis  or  tumors,  more  especially  those 
of  a  malignant  type.  Tumors  of  the  prostate,  particularly  cancer, 
exhibit  pain  in  the  prostate  as  one  of  their  most  characteristic 


GENERAI.  EXAMINATION   OF   PATIENTS  23 

symptoms,  but  this  does  not  necessarily  give  rise  to  painftil  mic- 
turition unless  the  disease  has  advanced  beyond  the  prostatic 
capsule.  Pain  in  the  glans  penis  is  often  caused  by  stone  in  the 
bladder,  and  is  less  often  associated  with  cystitis  or  gravel,  which 
gives  rise  to  painful  urination.  Marked  neurasthenics  are  oc- 
casionally subject  to  spasmodic  attacks  of  tenesmus,  which  occur 
in  the  day-time,  never  at  night,  last  for  an  hour  or  two,  and  pass 
away.  These  attacks  resemble  those  occurring  from  gravel.  As 
a  general  rule,  gradual  recovery  follows.  The  origin  of  these 
attacks  is,  at  the  present  time,  unknown. 

An  inquiry  into  urinary  retention,  partial  or  complete,  may 
elicit  valuable  information.  Complete  retention  is  in  most  in- 
stances due  either  to  stricture,  more  apt  to  occur  in  early  Hfe,  or  to 
an  enlarged  prostate,  the  latter  being  usually  the  case  in  the  aged. 
Rupture  of  the  urethra,  coagulated  blood  in  the  bladder,  and 
various  forms  of  apoplexy  and  paralysis  may  cause  retention. 
It  also  frequently  follows  a  surgical  operation  for  hemorrhoids, 
gynecologic  operations,  or  excessive  tamponade.  A  condition  of 
chronic  retention  may  be  caused  by  overdistention  of  the  bladder 
and  by  hypertrophied  prostate. 

Incontinence  may  be  due  to  acute  urethritis  and  to  prostatic 
disease;  almost  any  injury  of  the  muscles  about  the  neck  of  the 
bladder  may  act  as  a  cause,  and  in  children  it  is  often  seen  as  the 
result  of  inefficient  innervation.  New-growths  and  diseases  of  the 
spinal  cord  are  also  causes.  Suprapubic,  urethrorectal,  or  perineal 
fistulas  occurring  after  operations  or  as  a  result  of  tuberculosis 
may  give  rise  to  this  condition.  It  more  frequently  follows  a 
suprapubic  or  a  urethrorectal  than  a  perineal  fistula. 

Questions  should  be  asked  concerning  the  gross  character  of  the 
urine  passed,  whether  its  color  is  normal,  dark,  light,  bloody,  black, 
or  milky.  In  diabetes,  nervous  conditions,  and  chronic  diseases 
of  the  upper  urinary  tract  straw-colored  urine  is  the  rule.  Black 
urine,  or  that  which  becomes  black  after  standing  a  short  time,  is 
frequently  due  to  the  ingestion  of  carbolic  acid  or  other  hemolytic 
substances,  but  occasionally  it  is  due  to  the  formation  of  a  substance 
called  melanin ;  this  last  renders  the  urine  cloudy,  with  the  depo- 
sition of  black,  sooty  particles,  as  onchronosis.  When  the  urine  is 
bloody,  it  may  be  of  a  dark  hue,  and  is  then  probably  due  to  hemor- 


24  GENERAL   EXAMINATION    OF   PATIENTS 

rhage  in  the  upper  urinary  passages.  Clot  formations  in  the 
ureter,  passed  out  in  the  urine,  and  resembhng  earthworms,  are 
diagnostic  of  renal  hemorrhage.  Bloody  urine  is  often,  of  course, 
due  to  disease  of  the  bladder  or  ureter;  fresh  colored  blood  in  the 
urine  is  usually  the  result  of  disease  of  the  urethra.  Blood  is  seen 
in  the  urine  after  certain  forms  of  trauma,  stone,  after  the  ingestion 
of  various  drugs,  such  as  cantharides,  or  as  an  accompaniment  of 
infectious  diseases,  such  as  typhoid  fever  and  malaria.  Malarial 
fever  may  not  infrequently  give  rise  to  hematuria.  Blood  in  the 
urine  may  be  the  first  symptom  of  tuberculosis  of  the  urinary 
tract,  especially  of  the  kidney.  Milky  colored  urine  may  be  due 
to  the  admixture  of  pus  or  to  phosphaturia  or  chyluria;  and  thick, 
brownish-colored  urine  to  the  presence  of  urates.  Filaria  and 
various  forms  of  parasites  may  give  rise  either  to  bloody  or  to 
chylous  urine. 

The  history  of  previous  diseases  should  be  thoroughly  inquired 
into,  since  such  diseases  as  scarlatina,  syphilis,  or  even  previous 
attacks  of  urethritis  cause  changes  in  the  kidneys.  A  knowledge 
of  the  habits  of  the  patient's  life,  his  occupation,  and  the  climate 
to  which  he  has  been  accustomed  will  also  be  of  assistance  not 
only  in  the  making  of  a  correct  diagnosis,  but  also  in  indicating 
the  prognosis  and  formulating  the  treatment.  All  observers  are 
agreed  as  to  the  difficulty  in  effecting  a  cure  in  so  common  a  con- 
dition as  urethritis  in  persons  subject  to  much  vibration,  such  as 
railroad  employees  or  automobilists  experience. 

Occupational  diseases,  as  a  whole,  are  thrusting  themselves  for- 
ward for  consideration  with  increased  frequency  owing  to  the  com- 
plexity of  life,  and  may  be  responsible  for  marked  changes  in  the 
urinary  system. 

Geographic  Conditions. — Owing  to  the  marked  diversity  in  the 
habits  of  life  in  different  localities  as  regards  food,  drink,  and  in 
the  character  of  fluids  ingested,  a  knowledge  of  these  facts  is  neces- 
sary. Due  to  immigration  these  facts  are  of  very  real  importance 
in  this  country.  Diabetes  and  stone  formation,  for  example,  may 
be  mentioned  in  this  connection.  Observations  are  being  more 
and  more  frequently  recorded  of  the  effects  of  microbic  infection, 
usually  confined  to  certain  geographic  areas,  as,  for  example,  in  the 
relapsing  fevers.      Filaria  sanguinis  hominis  is  extremely  com- 


GENERAL   EXAMINATION    OE   PATIENTS  25 

mon  in  Porto  Rico,  and  in  certain  parts  of  South  America  is  an 
illustration  of  this.  It  causes  among  other  lesions  marked,  diver- 
sified, and  interesting  changes  in  the  urinary  organs,  as  well  as 
being  one  of  the  principal  causes  of  elephantiasis.  This  subject 
is  again  referred  to  fiu"ther  on  under  Diseases  of  the  Testicles. 

Information  can  also  be  obtained  by  inquiring  into  the  sexual 
life  of  the  patient,  and  the  importance  of  the  numerous,  though 
frequently  minor,  sexual  perversions  is  obvious. 

These  manifold  questions  demand  painstaking  effort  on  the 
part  of  the  examiner;  but  if  while  so  doing  he  is  able  to  encourage 
the  confidence  of  his  patient  and  if  his  judgment  is  sufficiently  keen 
and  his  faculties  in  general  are  sufficiently  discriminative  to  enable 
him  to  ascribe  the  proper  clinical  import  to  the  facts  elicited,  the 
diagnosis,  which  often  can  be  reached  in  no  other  way,  will  be 
sufficiently  accurate  to  reward  his  efforts. 

General  inspection  of  the  patient  may  follow  the  questioning. 
His  actions  and  the  manner  in  which  he  replies  having  previously 
been  noticed,  his  body  should  now  be  carefully  examined.  In 
some  diseases  of  the  kidney,  bladder,  and  prostate  the  hair  pre- 
sents a  dry  and  brittle  appearance  that,  once  seen,  is  easily  recog- 
nized. In  secondary  syphilis,  round  patches  of  alopecia  are  fre- 
quently seen.  Any  eruption  on  the  face,  neck,  or  trunk,  old  scars, 
and  growths  may  all  tell  their  tale.  Disturbances  of  the  pupil 
may  be  indicative  of  locomotor  ataxia,  which  is  often  mistaken  for 
some  disease  of  the  urinary  apparatus,  an  error  that  should  be 
guarded  against.  The  condition  and  shape  of  the  teeth  may  show 
the  result  of  hereditary  syphilis.  Important  aid  may  be  obtained 
from  studying  the  color  of  the  lips,  a  bluish  hue  indicating  possible 
venous  stasis,  polyglobulism,  mitral  disease,  etc.  The  position  of 
the  apex-beat  of  the  heart,  especially  if  it  occurs  below  or  to  the 
left  of  the  normal  point,  is  well  worth  ascertaining.  The  cremas- 
teric, knee-jerk,  and  ankle-clonus  reflexes  should  be  tested.  The 
power  of  coordination  should  be  investigated  by  the  simpler  tests, 
such  as  having  the  patient  stand  with  his  eyes  closed  and  his  heels 
and  toes  together  and  bringing  the  index-fingers  in  apposition. 
Cases  of  disturbed  urinary  function  difficult  of  diagnosis  have  been 
brought  under  our  observation  in  which  the  increased  knee-jerk 
reflex  seemed  to  eliminate  locomotor  ataxia  and  in  which  the 


26  GENERAL   EXAMINATION   OP   PATIENTS 

patients  were  not  neurasthenic,  the  increased  reflexes  afterward 
proving  to  be  due  to  a  myeHtis  that  preceded  the  onset  of  locomo- 
tor ataxia.  Undoubtedly  many  somewhat  similar  cases  are  con- 
founded with  organic  disease  of  the  urinary  tract,  the  practitioner 
failing  to  grasp  the  significance  and  seriousness  of  the  existing 
nervous  symptoms.  Involuntary  muscular  contractions  should 
be  inquired  into.  A  tendency  to  lift  one  leg  is  often  indicative  of 
abscess  formation  on  that  side,  and  is  associated  frequently  with 
pyelonephritis. 

A  physical  examination  by  means  of  percussion  and  palpa- 
tion, and  an  examination  of  the  secretions  should  now  be  made 
before  proceeding  to  instrumental  examination.  It  is  very 
often  possible,  as  the  result  of  questioning  alone  and  through 
a  process  of  exclusion,  to  arrive  at  a  fairly  accurate  diagnosis. 
The  physical  examination  of  the  kidneys  is  elsewhere  considered, 
but  will  be  merely  alluded  to  here.  Casper  states  that  by  per- 
cussion it  may  be  possible  to  diagnose  a  kidney  tumor  from  an 
intestinal  tumor,  as  the  latter  gives  rise  to  a  tympanitic  sound; 
personally,  we  have  not  been  able  to  obtain  much  information 
from  percussion.  The  statement,  so  widely  believed,  that 
a  kidney  tumor  will  fall  backward  when  the  patient  is  lying  on 
his  back,  with  pelvis  and  legs  lifted,  is  a  method  of  differentiation 
that  we  have  also  found  of  no  use.  Clinically,  we  have  found  that 
tumors  of  the  kidney  can  be  accurately  differentiated  from  those 
involving  neighboring  organs  only  by  exploratory  operation. 
However,  palpation  with  percussion  will  often  be  the  means  of 
determining  the  presence  or  absence  of  tumors  of  the  kidney  or 
neighboring  organs.  In  order  to  obtain  the  best  results  from  pal- 
pation of  the  kidney  the  patient  should  be  on  his  back,  with  knees 
flexed,  but  avoiding  all  tension  of  the  abdominal  muscles;  the 
examiner  should  place  one  hand  beneath  the  back  and  press  up- 
ward between  the  crest  of  the  ilium  and  the  last  rib ;  the  other 
hand  should  be  placed  directly  over  this,  and  press  downward  on 
the  abdominal  wall.  A  similar  procedure  may  be  carried  out 
with  the  patient  lying  on  one  side  or  standing  and  bending  over  a 
chair. 

As  mentioned  in  the  chapter  on  the  Kidney,  it  is  well  to  mas- 
sage and  manipulate  the  abdomen,  following  the  course  of  the 


GENERAL  EXAMINATION   OF   PATIENTS  27 

ureter  in  the  case  of  suspected  pyelonephritis ;  as  a  result  of  this 
manipulation  pus  or  an  increased  amount  of  it  will  be  noticed 
in  the  lu-ine.  Pyelonephritic  kidneys  are  usually  tender  on 
pressure,  although  it  is  sometimes  difficult  to  determine  whether 
the  tenderness  is  due  to  a  diseased  kidney  or  to  some  other  con- 
dition, such  as  the  result  of  injury  or  arthritis  of  the  sacro-iliac 
synchondrosis. 

Percussion  and  palpation  of  the  bladder  region  are  occasionally 
of  value.  It  should  be  remembered  that  patients  suffering  from 
prostatic  hypertrophy  may  have  thickened  bladder-walls,  or,  as  a 
result  of  retention,  the  bladder  may  be  much  distended.  This 
latter  condition,  together  with  a  thickened  bladder-wall,  w^e 
have  known  mistaken  for  an  abdominal  tumor.  In  any  one,  male 
or  female,  even  if  no  history  of  retention  has  been  given,  in  whom 
the  presence  of  an  abdominal  tumor  is  suspected,  unless  its  nature 
can  be  very  clearly  determined  by  other  means,  it  is  well  to 
catheterize  the  bladder  and  study  the  results.  The  groins  should 
be  palpated  to  ascertain  the  presence  or  absence  of  hernia.  Re- 
tained testicle  should  be  looked  for,  and  the  general  appearance 
of  the  genital  organs  observed.  The  condition  of  the  foreskin 
should  be  learned,  and  disease  of  the  testicle  or  ulceration  of  the 
scrotum  looked  for.  The  nature  of  the  scrotal  contents  should  be 
ascertained,  for  it  should  be  remembered  that  tuberculosis  is  prone 
to  cause  early  invasion  of  the  testicle  or  epididymis. 

An  examination  of  the  heart  will  reveal  any  tendency  toward 
enlargement,  either  from  the  dilatation  or  the  hypertrophy  so 
closely  associated  with  kidney  disease.  The  pulse,  either  with 
or  without  sphygmographic  tracings,  will  give  some  conception 
of  the  amount  of  arterial  pressure  or  as  to  the  extent  of  arte- 
rial disease.  The  temperature  will  indicate  the  presence  or  ab- 
sence of  fever,  which  may,  perhaps,  have  its  origin  in  the 
urethral  canal. 

Urinary  fevers  may  be  divided  roughly  into  three  classes : 

I.  There  is  a  continuous  form  that  comes  on  a  few  hours  after 
catheterization,  rupture  of  the  urethra,  or  some  form  of  trauma; 
it  is  generally  inaugurated  by  a  chill,  followed  by  high  temperature, 
which  subsides  in  a  day  or  two  at  the  most,  when  convalescence 
ensues.     Occasionally  this  fever  is  of  a  fulminating  character,  the 


28  GENlBRAIv   EXAMINATION   OF   PATIENTS 

temperature  remaining  very  high,  death  sometimes  occurring  in 
a  comparatively  short  time. 

2.  The  second  form  of  urinary  fever  is  intermittent  in  charac- 
ter, with  only  a  slight  rise  in  temperature,  followed  by  a  return 
to  the  normal,  and  then  another  rise;  cUnically  this  resembles 
mild  malarial  fever.  It  may  be  due  to  injury  caused  by  improper 
instrumentation,  or  it  may  be  associated  with  the  presence  of  pus 
in  the  prostate,  kidney,  bladder,  or  elsewhere. 

3.  The  third  class  is  of  a  remittent  type,  the  temperature, 
while  not  high,  never  reaching  the  normal  until  convalescence. 
Just  as  in  gangrene  of  the  appendix  or  other  organs,  it  occasionally 
happens  that  an  abscess  in  the  urinary  tract  may  cause  such  pro- 
found sepsis  as  to  result  fatally  without  exhibiting  a  rise  in  tem- 
perature. We  have  met  such  a  case  due  to  a  large  abscess  in  the 
prostate,  and  this  character  of  temperature  course  seems  to  be  par- 
ticularly frequent  in  unruptured  prostatic  abscess. 

In  most  fatal  cases  of  urinary  sepsis  attended  with  fever  post- 
mortem examination  reveals  multiple  abscesses  of  the  kidney. 
When  death  has  resulted  directly  or  indirectly  from  stricture  or 
from  prolonged  retention,  the  postmortem  shows  that  dilatation 
of  the  ureters  takes  place,  that  the  pelvis  of  the  kidney  has  become 
infected,  and  that  multiple  abscesses  have  formed  in  the  kidneys 
as  the  terminal  process  in  the  disease. 

The  examination  of  the  prostate  may  profitably  be  postponed 
until  after  instruments  have  been  passed  into  the  urethra,  should 
the  diagnosis  necessitate  the  latter  measure.  By  observing  this 
rule  the  danger  of  urethral  infection  is  somewhat  lessened.  But 
when  instrumentation  is  not  to  be  resorted  to,  the  examination 
of  the  prostate  may  terminate  the  general  physical  examination. 
A  thorough  examination  of  this  gland  can  best  be  made  with  the 
finger  in  the  rectum  after  an  instrument  has  been  placed  into  the 
bladder  and  allowed  to  remain  there;  this  affords  a  means  of 
estimating  the  distance  between  the  finger  and  the  instrument. 
The  ordinary  procedure  for  prostatic  examination  through  the  rec- 
tiun  is  to  have  the  patient  bend  over  a  chair  or  a  table ;  the  examiner 
introduces  the  forefinger  of  the  right  hand,  covered  with  a  well-lu- 
bricated finger-tip,  into  the  rectum,  and  searches  for  any  enlarge- 
ment or  thickening  of  the  prostate  or  of  the  seminal  vesicles. 


GENERAL  EXAMINATION   OF  PATIENTS 


29 


Any  diflference  between  the  two  lobes  can  be  ascertained  at  the 
same  time,  also  any  points  of  softening  that  might  be  indicative 
of  a  prostatic  abscess.  When  the  latter  condition  exists,  a  sort  of 
dimple  will  probably  be  present  in  the  prostate.  When  the 
abscess  is  extensive,  slight  massage  of  the  side  of  this  dimple  may 
cause  pus  to  exude  from  the  meatus.     Should  the  patient  urinate 


Fig.  I. 


-Examination  of  the  prostate  by  the  rectum  only.    Also  position  for  massage  of  the 
prostate. 


after  the  massage,  if  abscess  of  the  prostate  is  present,  the  urine 
will  usually  contain  large  quantities  of  pus.  When  the  seminal 
vesicles  are  enlarged,  they  will  ordinarily  be  found  to  run  off  like 
cords,  at  an  angle  with  the  apex  of  the  prostate,  forming  with  it  a 
triangle  whose  base  is  the  base  of  the  bladder  and  whose  apex  is  the 
prostate.  Massage  may  also  be  applied  to  the  seminal  vesicles  and 
to  the  prostate  for  the  purpose  of  obtaining  their  contents  for 


30  GENERAIv  EXAMINATION   OF   PATIENTS 

microscopic  examination  and  for  the  purpose  of  locating  painful 
areas. 

With  thin  male  subjects  it  is  well,  besides  examining  the  pros- 
tate through  the  rectum  by  the  method  previously  suggested,  to 
place  the  patient  on  his  back,  and  to  introduce  the  forefinger  of  the 
one  hand  into  the  rectum  and,  with  the  other  hand  on  the  abdo- 
men, to  press  down  over  the  suprapubic  region.  Considerable 
experience  is  necessary  to  correctly  diagnose  diseased  conditions 
of  the  prostate  or  seminal  vesicles  by  means  of  rectal  examination 
alone,  no  instrument  at  the  time  being  present  in  the  bladder,  and 
we  find  that  even  intelligent  members  of  house  staffs  in  hospitals 
are  repeatedly  making  mistakes  as  to  the  findings  derived  from 
that  procedure  and  drawing  false  conclusions  from  it.  The 
mistake  most  frequently  made  is  that  of  supposing  an  enlarge- 
ment of  the  prostate  or  seminal  vesicles  to  exist  when  none  is 
present.  Information  concerning  a  stone  in  the  bladder  can  rarely 
be  ascertained  by  rectal  examination,  and  still  more  rarely  is  it 
possible  to  learn  the  condition  of  the  ureters  in  the  male  by  this 
method. 

In  women  a  vaginal  examination  may  give  considerable 
information  as  to  the  condition  at  the  base  of  the  blad- 
der, and  when  made  bimanually,  as  to  the  condition  of  the 
ureters. 

An  examination  of  the  secretions  is  the  next  step  in  order,  and  it 
is  best  that  this  be  made,  in  part  at  least,  at  the  patient's  first 
visit.  When  tuberculosis  is  suspected,  prolonged  examination  is 
necessary  to  detect  the  presence  of  the  tubercle  bacillus  with  abso- 
lute certainty,  and  some  time  must  elapse  before  the  diagnosis 
can  be  arrived  at.  Other  conditions,  however,  may  be  more  sum- 
marily dealt  with.  In  cases  of  acute  urethritis  the  discharge  may 
be  washed  out  from  the  urethra  as  far  as  the  bulb,  and  the  urine 
may  then  be  passed  and  collected  for  examination.  After  this 
process  the  bladder  may  be  washed  out,  emptied,  and,  if  thought 
advisable,  the  prostate  massaged,  and  an  attempt  at  urination 
made.  A  few  drops  of  this  urine  should  be  preserved  for  a  future 
examination,  in  order  to  ascertain  the  condition  of  the  prostate 
and  seminal  vesicles.     In  those  individuals  in  whom  no  acute  dis- 


GENERAL   EXAMINATION    OF  PATIENTS  3 1 

charge  is  present,  washing  out  of  the  anterior  urethra  will  be  un- 
necessary; the  patient  should,  however,  be  requested  to  urinate, 
and  the  urine  be  set  aside  for  examination  or  a  simple  examination 
immediately  made. 

We  have  found  some  of  the  glass  tests  advocated  for  the  purpose 
of  locating  the  seat  of  urethritis  to  be  misleading.  One  of  these 
fallacious  tests  is  to  have  the  patient  pass  half  the  urine  into  one 
glass  and  half  into  another.  If  the  urine  in  the  second  glass  is 
clear,  whereas  cloudiness  or  shreds  are  present  in  the  other,  this  has 
often  been  thought  to  prove  conclusively  that  the  inflammation  is 
confined  to  the  anterior  urethra.  This  test  has  been  proved  to  be 
unreliable,  since  if  but  a  slight  amount  of  discharge  were  present, 
it  could  be  washed  out  with  the  first  half  of  the  urine  passed,  even 
when  the  inflammation  extended,  as  it  usually  does,  throughout 
the  entire  urethral  tract.  The  test  may,  however,  have  a  relative 
value  if  made  when  a  large  amount  of  urine  is  in  the  bladder,  as  on 
the  first  urination  after  rising.  If  both  glasses  are  then  found  to  be 
cloudy,  and  the  patient  is  asked  to  urinate  in  the  same  manner 
later  in  the  day,  when  the  bladder  contains  but  a  small  amount,  and 
all  the  cloudiness  is  found  to  be  confined  to  the  first  glass,  this 
would  indicate  the  existence  of  a  posterior  urethritis ;  if,  however, 
then  neither  glass  is  clear  and  the  cloudiness  is  seen  microscopically 
to  be  due  to  pus,  or  the  shreds  to  be  made  up  of  pus-corpuscles,  a 
cystitis  or  kidney  involvement  would  be  demonstrated.  If  the 
early  morning  urine  is  collected  in  three  glasses  and  all  are  found 
to  be  cloudy  and  to  contain  pus  or  numerous  shreds,  it  indicates, 
generally,  that  the  inflammation  is  beyond  the  posterior  urethra. 
These  various  glass  tests  will  be  referred  to  again  under  the 
Diagnosis  of  Urethritis   (p.  425). 

The  chemic  examination  of  the  urine  is  dealt  with  in  more  detail 
elsewhere  (p.  112),  but  there  are  several  valuable  simple  tests 
for  learning  some  of  its  possible  constituents  that  may  be  made 
expeditiously  at  the  time  the  patient  is  being  examined.  Cloudy 
urine  is  ordinarily  due  to  the  presence  of  mucus,  pus,  bacteria, 
urates,  phosphates,  carbonates,  or  albumin;  a  simple  test  for 
determining  to  which  of  these  agents  the  cloudiness  is  due  has 
been  outlined  by  Ultzmann,  of  Vienna.     A  portion  of  the  urine 


32  GENERAL  EXAMINATION   OF   PATIENTS 

is  placed  in  a  test-tube  and  the  upper  portion  boiled.  If  it  imme- 
diately becomes  clear,  the  cloudiness  is  due  to  the  presence  of 
urates;  if  it  becomes  more  cloudy,  to  phosphates,  carbonates,  or 
albumin ;  and  if  it  remains  unchanged,  to  pus  or  mucus.  If,  then, 
by  adding  a  drop  of  dilute  acetic  acid  to  the  urine  it  is  immediately 
clarified,  the  cloudiness  was  due  to  an  excess  of  phosphates ;  and  if, 
in  addition,  it  effervesces  in  clearing  up,  it  was  due  to  carbonates. 
If  it  becomes  still  more  cloudy,  albumin  is  present,  and  if  it  remains 
unchanged,  pus,  mucus,  or  bacteria  may  be  said  to  be  present. 

A  very  popular  test  for  mucus  or  pus  is  to  add  an  equal  amount 
of  liquor  potassae  to  the  urine  in  the  tube ;  shake  the  tube  well, 
and  if  the  mixture  shows  considerable  cloudiness,  particularly 
if  of  a  stringy  character,  the  presence  of  pus  or  mucus  may  be 
said  to  be  established. 

It  is  hardly  necessary  to  state  that  when  the  presence  of  any 
of  the  above-mentioned  substances  has  been  detected,  these  tests 
must  be  further  confirmed  by  means  of  more  accurate  methods. 

THE  INSTRUMENTAL  EXAMINATION 
The  verbal  and  physical  examination  of  the  patient  having 
been  completed  and  the  urinary  and  other  secretions  of  the  body 
having  also  been  examined,  it  is  often  necessary,  in  addition,  as 
previously  mentioned,  to  complete  the  examination  by  the  intro- 
duction of  some  instruments,  such  as  a  catheter,  bougie,  sound, 
searcher,  or  possibly  endoscope  or  cystoscope,  into  the  urethra  or 
bladder.  A  detailed  description  of  all  these  instruments  is  unneces- 
sary; the  following  are  those  that  have  given  the  most  satisfac- 
tion in  the  writer's  hands.  For  ordinary  purposes  of  catheter, 
ization,  the  soft-rubber,  velvet-eyed  catheter  is  probably  the  form 
most  generally  used.  The  smaller  catheters  are  to  be  preferred 
to  the  larger.  No  catheter  should  be  used  ordinarily  that  has 
any  hole  besides  the  eye,  and  care  should  be  taken  that  there 
are  no  rough  places  on  the  instrument  that  might  scratch  the 
urethra — particularly,  that  there  is  no  roughness  about  the  eye. 
Often,  after  very  little  use,  the  edges  of  the  eye  of  the  catheter 
become  roughened.  This  should  be  particularly  guarded  against 
where  the  services  of  a  physician  or  of  a  trained  attendant  cannot 
be  procured,  and  where  the  patient  must  be  taught  to  use  the 


THE   INSTRUMENTAL   EXAMINATION  33 

instrument  himself.  The  shafts  of  these  catheters,  as  ordinarily 
made,  are  round.  Soft-rubber  catheters,  somewhat  flattened  at 
the  lower  end,  have  recently  been  put  on  the  market.  They  are 
said  to  be  useful  in  cases  of  enlarged  prostate ;  the  urethra  being 
stretched  by  the  prostatic  enlargement,  is  necessarily  generally 
narrowed  from  side  to  side,  and  a  catheter  somewhat  flattened  on 
the  side  will  thus  more  easily  conform  to  the  shape  of  the  canal. 
They  are  also  made  flattened  at  the  top  and  the  bottom.  Soft- 
rubber  catheters  have  very  little  penetrating  force,  their  intro- 
duction being  easily  hindered  by  stricture  of  the  urethra ;  in  cases 
of  enlarged  prostate,  moreover,  where  the  prostate  alters  the 
natural  curve  of  the  urethra,  they  are  particularly  likely  to  curl 
up  at  the  bulbomembranous  junction.  They  are  also  introduced 
with  difficulty  if  a  spasm  of  the  urethral  muscle — a  so-called 
spasmodic  stricture — exists. 

Catheters  of  gummed  linen  or  silk  with  flexible  olive  ends  pre- 
ceding the  entrance  of  the  eye  are  extremely  useful,  when  pro- 
perly constructed.  They  are  of  value  not  only  for  the  ordinary 
purpose  of  a  catheter  to  empty  the  bladder,  but  are  useful  for 
examining  the  urethra  in  both  its  anterior  and  its  posterior  por- 
tions, as  the  flexible  bulbous  point  very  easily  detects  any  irregu- 
larity in  the  canal.  Then,  too,  they  are  useful  as  a  means  of  mak- 
ing applications  to  the  posterior  urethra  and  bladder.  In  choos- 
ing catheters  of  this  description  great  care  should  be  exercised. 
As  ordinarily  made  in  this  country,  the  olive-pointed  ends  are  too 
inflexible,  and  the  catheters  partake  too  much  of  the  nature  of  an 
Indian  arrow.  Such  instruments  are  likely  to  do  more  harm  than 
good.  When  the  ends  are  extremely  flexible,  however,  they  are 
useful  in  overcoming  urethral  obstacles,  such  as  strictures  of  not 
too  small  caliber;  they  are  more  useful  than  soft  catheters  in 
overcoming  spasms  at  the  neck  of  the  bladder,  and  if  flexible  enough 
and  not  too  large,  will  not  irritate  the  urethra.  Ordinarily  they 
can  be  introduced  into  the  bladder  with  less  pain  to  the  patient 
than  any  other  form  of  catheter.  For  emptying  the  bladder, 
where  this  must  be  done  rapidly,  they  are  not,  as  a  rule,  so  service- 
able as  some  others,  and  in  old  prostatics,  with  large  quantities 
of  residual  urine,  or  in  cases  where  a  large  amount  of  fluid  is  to 
be  evacuated  from  the  bladder,  they  may  not  be  found  so  prac- 
3 


34  GENERAL   EXAMINATION    OF    PATIENTS 

tical  as  the  soft-rubber  catheters  or  those  of  some  other  shape  or 
material,  on  account  of  their  comparatively  small  lumen.  Ordi- 
narily, they  may  be  procured  in  two  forms — those  whose  upper 
extremity  is  of  the  same  circumference  as  the  shaft,  and  those  in 
which  the  upper  extremity  is  funneled,  in  order  that  the  fluid  may 
be  more  easily  injected  through  them  by  means  of  the  nozzle  of  a 
syringe.  For  this  same  purpose  a  small  piece  of  rubber  tubing  may 
be  attached  to  the  upper  extremity  and  the  nozzle  of  the  syringe 
introduced  into  this.  These  have  been  found  more  useful  than 
any  other  instrument  for  the  purpose  of  irrigating  the  deep 
urethra  and  the  bladder.  The  best  of  these  instruments  are  those 
made  in  France.  The  most  practical  for  use  are  Nos.  lo  and  12 
French. 

Being  unirritating,  they  are  useful  for  purposes  of  irrigation 
where  it  is  desired  to  introduce  quite  a  large  quantity  of  fluid 
along  the  floor  of  the  posterior  urethra  and  into  the  bladder.  They 
are  also  very  useful  for  purposes  of  instillation — that  is,  the  pro- 
cess by  which  a  few  drops  of  fluid,  generally  some  strong  solution, 
are  applied  to  the  neck  of  the  bladder. 

The  uselessness  of  a  multiplicity  of  instruments  has  often  been 
proved.  Clinical  experience  has  demonstrated  that  these  simple 
bulb-pointed  flexible  tipped  catheters  are  useful  for  purposes  for 
which  many  different  forms  of  instruments  are  advocated.  Silk 
gum  catheters  with  stylets — the  stylet  being  introduced  for  the  pur- 
pose of  making  them  unyielding  and  permitting  them  to  be  bent 
into  any  desirable  shape — have  often  been  used  in  the  past  and 
are  still  recommended  by  some  as  the  best  form  of  catheter  for  use 
by  old  men  who  are  obliged  to  use  one  constantly.  Their  value 
has  probably  been  very  much  overrated.  An  ordinary  soft-rubber 
catheter  is  the  safest  one  for  the  individual  to  use  on  himself. 
When,  because  of  malformation  of  the  prostate,  the  soft  catheter 
cannot  be  made  to  penetrate,  one  of  the  larger  sizes  of  the  French 
olive-tipped  flexible  catheters,  just  described,  should  be  tried. 
That  failing,  one  of  the  particular  shape  best  adapted  to  overcome 
the  particular  form  of  prostatic  obstruction  present  should  be  used. 

There  are  three  forms  of  these  catheters:  the  "Mercier 
coude,"  "bicoude,"  and  the  large  prostatic  curve  (see  figs. 
2,  3,  4,  5).     The    instruments   with  the    large   curves   are   ordi- 


THE   INSTRUMENTAL   EXAMINATION 


35 


narily  made  of  metal,  and  the  smaller  are  made  of  either  metal 
or    silk.     The    simpler    curves,    such    as    the    "Mercier    coude," 


Fig.  2.— German  silver  metal  catheter,  with  ordinary'  urethral  curve. 

should  first  be  tried  in  an  endeavor  to  pass  through  an  obstructed 
prostatic  urethra;  if  these  fail  to  pass,  the  "bicoude,"  or  the  cath- 


Fig.  3. — Mercier"s  coude  catheter. 


eter  with  the  large  prostatic  curve,  may  be  tried.     Often  a  metal 
catheter  with  the  ordinarv  normal  urethral  curve  will  be  found 


JS) 


Fig.  4.— Mercier'sbicoude  metal  catheter. 


useful.     It  is  advisable  to  keep  on  hand  a  series  of  metal  catheters 
of  the  following  four  types :    "Normal  curve,"  "Mercier,"  "coude," 


Fig.  5. — Metal  catheter  with  prostatic  curve. 


"bicoude,"  and  large    "prostatic"  curve.     The  use  of  retention 
catheters  is  coming  into  increased  favor.     They  usually  consist 


36 


GENERAL  EXAMINATION   OF   PATIENTS 


of  an  instrument  with  a  collar,  the  Pezzer  retention  catheter 
(fig.  7),  or  a  catheter  with  a  wing  on  each  side,  the  Malecot  re- 
tention catheter  (fig.  8);  the  catheter  being  introduced  into 
the  bladder,  the  collar  or  wing  prevents  its  escape  unless  some 
ilttle  traction  is  used  by  the  attending  surgeon.     An  ordinary- 


Fig.  6. — Method  of  tying  catheter  in  bladder. 


catheter  may  be  held  in  place  in  the  bladder  by  fastening  linen 
threads  around  the  glans,  or  by  the  use  of  adhesive  plaster. 
These  retention  catheters  sometimes  remain  in  place  for  a  period 
of  two  weeks  without  necessitating  removal  or  causing  much  irrita- 
tion.   It  not  infrequently  happens  that  in  those  cases  in  which  it  is 


THE    INSTRUMENTAL   EXAMINATION  37 

most  desirable  that  a  catheter  be  retained,  as  after  operations  on 
tubercular  subjects,  this  will  not  be  found  feasible.  A  retention 
catheter  must  generally  be  eventually  removed  because  of  the 
local  irritation  it  produces  inside  the  bladder  at  its  neck;  its  pres- 
sure sometimes  sets  up  a  general  urethritis. 

ZuckerkandP  considers  that  a  retention  catheter  can  be  retained 
longer  without  causing  irritation,  the  urethra  being  better  pro- 
tected from  infection  from  the  outside  if  a  spica  bandage,  com- 


Fig.  7. — Pezzer  retention  catheter. 

mencing  at  the  base  of  the  shaft  of  the  penis,  is  wound  around  it 
to  the  glans,  over  the  glans,  and  for  an  inch  or  two  on  the  shaft  of 
the  catheter,  the  other  end  of  the  catheter  being  run  through 
sterilized  cotton  in  the  neck  of  the  bottle  or  other  receptacle  that 
is  to  receive  the  urine. 

Bougies  are  instruments  made  of  gummed  silk  or  linen,  and  are 
used  for  the  purpose  of  examining  the  urethral  canal  or  for  dilat- 


Fig.  8.— Malecot  retention  catheter. 

ing  strictures.  Filiform  bougies,  so  called  from  their  minute  size, 
are  ordinarily  used  as  guides  to  effect  an  entrance  into  the  bladder 
in  cases  of  retention  from  stricture  of  the  urethra.  Ordinarily 
they  are  made  of  whalebone,  although  the  very  small  ones  recently 
introduced  are  made  of  catgut.  These  catgut  bougies  are  useful 
little  instruments,  for  by  this  means  the  bladder  may  be  entered 

1  "  Die  Asepsis  in  der  Urologie,"  Friesch  and  Zuckerkandl,   "  Handbuch 
der  Urologie,"  Vienna,  1904. 


38  gkne;raIv  examination  of  patients 

when  all  other  forms  of  bougies  have  failed.  They  are  not,  how- 
ever, ordinarily  required,  and  are  very  easily  so  damaged  as  to 
unfit  them  for  use.  The  filiform  bougies  made  of  whalebone  are 
generallv  put  up  in  different  lengths,  the  longest  being  twice  that 
of  the  short  ones.  Where  it  is  impossible  to  obtain  the  assorted 
lengths,  the  long  ones  should  preferably  be  kept  on  hand.  In 
cases  of  stricture  in  a  long  urethra,  after  introducing  a  short  bougie 
into  the  bladder  it  occasionally  happens,  if  an  attempt  is  made 
to  run  a  tunneled  sound  over  it,  that  the  upper  end  of  the  bougie, 
if  a  short  one  is  used,  will  be  carried  into  the  urethra,  beyond  the 
meatus.  Whalebone  bougies  have  small  flexible  rounded  points 
on  their  ends;  others  end  with  straight  points,  and  still  others 
are   twisted.      The   choice    of   these   for    general   use    is   depen- 


Fig.  g. — Olivary  gum  bougie. 

dent  on  the  surgeon's  preference;  ordinarily,  when  it  is  possible 
to  pass  them,  the  round-tipped  ones  are  to  be  preferred,  A 
filiform  bougie,  made  of  whalebone,  of  the  ordinary  circumference 
of  the  filiform  at  the  lower  extremity,  but  with  a  long  shaft  grad- 
ually increasing  in  circumference,  has  been  on  the  market  for 
several  years  under  the  name  of  the  Banks  filiform,  or  whip  bougie. 
Experience  with  this  instrument  has  demonstrated  that,  being 
made  of  whalebone,  it  is  not  flexible  enough  to  possess  much  ad- 
vantage over  the  ordinary  filiforms.  To  overcome  this,  Tiemann 
&  Co.,  of  New  York,  have,  at  our  suggestion,  had  instruments  made 
in  Paris  of  the  same  shape  as  the  Banks  bougie,  gummed  silk  taking 
the  place  of  whalebone.  These  instruments  are  found  to  be  much 
more  flexible  and  useful,  and  are  recommended  as  a  useful  addition 
to  the  surgical  outfit  of  the  general  practitioner.  In  cases  of  stric- 
ture, the  flexible  point  having  passed  the  strictured  portion,  it  is 
only  necessary  to  keep  pushing  the  instrument  down  through  the 
urethra — the  lower  end  of  it  will  double  up  in  the  bladder  until 
the  largest  part  of  the  circumference  has  passed  the  strictured 
portion,  thus  dilating  the  stricture.     Following  the  removal  of 


THE   INSTRUMENTAIv    EXAMINATION  39 

this  instrument  a  silk,  olive-pointed  bougie  of  small  caliber  can 
ordinarily  be  passed.  These  olive-pointed  silk  bougies  may  be 
obtained  in  the  various  sizes  up  to  No.  20  French  or  larger.  They 
are  useful  for  dilating  strictures  of  small  caliber,  but  should  not, 
ordinarily,  be  used  of  a  circumference  larger  than  the  No.  20 
French;  when  it  is  desired  to  dilate  through  a  larger  opening, 
metal  instruments  should  be  substituted.  In  choosing  these 
bougies  it  is  always  well,  as  previously  stated,  to  obtain  those 
with  the  most  flexible  neck,  thus  lessening  the  danger  of  inflicting 
injury  on  the  urethra. 

Bougies  a  boule  are  used  for  examining  the  urethral  canal. 
They  may  be  had  in  varying  sizes.  They  are  made  of  either  rubber 
or  metal,  the  former  being  preferable,  and  are  useful  for  locating 


Fig.  10. — Otis'  metallic  bougie  a  boule. 

any  foreign  masses  or  other  constricting  lesions  that  may  exist 
in  the  anterior  urethra ;  they  are  also  useful  for  diagnosing  the 
various  forms  of  stricture  that  may  occur  there.  An  obstacle 
having  been  met,  the  largest  bougie  a  boule  that  will  pass  the 
obstacle  can  be  introduced  through  the  urethra;  if  the  next  size 
larger  will  not  penetrate,  a  correct  idea  may  be  had  as  to  the  cir- 
cumference of  the  urethra  at  the  strictured  portion.  These  in- 
struments are  not  to  be  recommended  in  the  treatment  of  disease, 
and  it  is  not  advisable,  ordinarily,  to  use  them  for  diagnostic  pur- 
poses or  for  detecting  or  treating  lesions  beyond  the  bulbomem- 
branous  junction.  For  ordinary  diagnostic  purposes  the  flexible 
olive-pointed  gum  bougie  previously  described  is  preferable. 

Various  ingenious  contrivances  have  been  devised  for  accurately 
measuring  the  circumference  of  the  anterior  urethra.  These 
instruments,  with  the  exception  of  the  bougies  a  boule  previously 
mentioned,  are  known  as  urethrometers.  The  only  one  that  will  be 
described  here  is  the  Otis  urethrometer,  which  was  designed  by 
the  late  Dr.  Fessenden  D.  Otis,  of  New  York.     It  fulfils  the  pur- 


40 


GENERAL   EXAMINATION   OF   PATIENTS 


pose  for  which  it   was  designed    so   well    that    any    description 
of    the    various    other    instruments,    mostly    of    foreign    make, 

invented  for  this  purpose  is  needless. 
The  instrument,  with  the  end  of 
the  shaft  closed,  is  passed  through 
the  strictured  portion  of  the  urethra 
and  distended  until  it  cannot  be  with- 
drawn because  of  the  obstacle  in  front 
of  it.  The  index  on  the  dial  plate 
will  show  the  circumference  of  the  ure- 
thra at  the  strictured  portion.  The 
end  can  then  be  contracted  enough  to 
allow  the  strictured  portion  to  be 
passed,  and  later  again,  as  the  instru- 
ment is  withdrawn,  distended  to  show 
the  presence  and  size  of  any  other  stric- 
tured portion  that  ma}"  be  met. 

Sounds  are  steel  instruments  varying 
from  Xos.  lo  to  40  French  scale,  and 
ordinarily  used  for  distending  the  ure- 
thra in  the  treatment  of  stricture ;  they 
are  also  introduced  for  their  general 
effect  in  reHeving  hyperemic  or  chron- 
ically congested  conditions  of  the  mu- 
cous membrane  of  the  urethra :  this  is 
accomplished  as  the  result  of  pressure. 
The  numbers  most  ordinarily  used  are 
from  Xo.  15  to  Xo.  35  French.  These 
sounds  are  obtained  with  curves  vary- 
ing as  regards  either  their  form  or 
length.  The  several  different  forms  of 
curve  ordinarily  on  the  market  have  about  the  same  degree 
of  usefulness.  Every  surgeon's  outfit  should  contain  a  few 
sounds  with  the  so-called  Benique  curv^e,  w^hich  are  partic- 
ularly useful  in  cases  of  enlarged  prostate.  Sounds  having  the 
Guyon  curve  are,  for  ordinan,'  purposes,  probably  as  good  as  any 
that  can  be  procured.     The   blunt-pointed  soimds  now  on  the* 


Fig.  II. — Otis"  latest  urethrometer. 


THE    IXSTRUMEXTAL    EXA^^NATION 


41 


market  are  undesirable,  there  being  ven."  little  difference  in  their 
size  from  their  extreme  end  to  their  full  circumference.  Ex- 
perience has  proved  that  such  sounds  are  much  more  difficult  to 
introduce  into  the  bladder  than  those  of  tapering  form.  It  must 
be  remembered  that  a  sound 
must  answer  the  purposes 
of  a  wedge  to  a  considerable 
extent,  and  it  should,  there- 
fore, be  shaped  accordingly. 

Straight  sounds  may  also 
be  had,  and  are  used  at 
tim.es  for  distention  of  stric- 
tures of  the  anterior  urethra. 

Searchers  are  instruments 
used  for  detecting  the  pres- 
ence of  stone  and  tumors 
in  the  bladder,  and  for  ob- 
taining a  general  idea  of 
the  topography  of  the  blad- 
der,  prostate,  and  urethra. 

Thev  are  made  in  various  shapes  and  forms,  but  the  Thompson 
searcher  is  the  one  most  generally  used.  Hollow  searchers  answer 
the  purpose  of  metal  catheters.  Their  use  is  described  in  detail 
in  another  portion  of  the  book.  In  purchasing  searchers  care 
should  be  taken  to  see  that  the  plug  at  the  upper  end  is  well 
fitted  in  and  is  secured  to  the  end  of  the  searcher  bv  a  chain. 


Fig.  12. — Showing  proper  (A)  and  improper  lE) 
conicitv  of  sound. 


Fig.  13, — Thompson's  searcher. 


Short  straight  sounds  of  large  diameter  are  useful  for  keeping 
the  meatus  distended  after  meatotomy  has  been  performed.  In- 
struments, such  as  the  cystoscope  and  the  endoscope,  which  are 
useful  for  examining  the  urethra,  under  direct  or  artificial  Hght, 
are  described  in  detail  elsewhere. 


42 


GENERAL   EXAMINATION   OF   PATIENTS 


Glass  syringes  may  be  had  in  several  different  forms,  having 
ordinarily  a  capacity  of  from  four  to  six  ounces;  the  advantage 
of  these  is  that  their  contents  are  visible.     For  general  urethral 


Fig.  14. — Janet  syringe. 

purposes,  however,  metal  syringes,  some  of  which  are  so  made 
that  they  can  be  easily  taken  apart  and  sterilized,  are  the  most 
useful. 


Fig.  15. — Janet  syringe. 

For  the  patient's  own  use,  blunt-pointed  glass  syringes  with  or 
without  rubber  ends  are  useful. 

For  bladder  irrigation   the  syringe  with  a   large  rubber  bulb 


Fig.  16.— Hayden-Janet  syringe. 


and  stop-cock,  as  illustrated  in  Fig  17,  is  the  one  that  will  be 
found  most  convenient  for  the  patient's  own  use,  where  an  en- 
larged prostate  gives  rise  to  the  necessity  for  catheter  life. 


CATHETERIZATION 


43 


In  addition,  there  are  various  forms  of  instruments,  some  of 
which  are  to  be  attached  to  the  syringe  especially  designed 
for  making   applications   to    the    deep   urethra.     The    two   best 


Fig.  17. — Rubber  bag  and  stopcock  for  injecting. 

known    of    these    are    the    Ultzmann    syringe,    for    instillation, 
and  the  Ultzmann  metal  catheter  for  irrigating  purposes. 

Instruments  to  be  used  for  similar  purposes  have  been  devised 
by  Guyon  and  many  others.  Experience  has  proved  that,  either 
for  instillation  or  for  irrigation,  as  good  results  can  be  obtained 


Fig.  18. — Ultzmann's  syringe  for  instillation. 

from  the  use  of  the  ordinary  flexible,  olive-pointed  silk  catheter  of 
small  caliber. 

CATHETERIZATION 

In  the  chapter  on  the  Sterilization  of  Instruments  and  the 


^r-^ 


Fig.  19.— Ultzmann's  irrigator  for  deep  urethra. 

Preparation  of  Patients  for  Operation  the  question  of  sterility  as 
regards  instruments  and  the  field  of  operation  in  catheterization 
is  considered  more  in  detail  (p.  90),  for,  after  all,  it  is  well,  as  has 


44  GENERAL    EXAMINATION   OF   PATIENTS 

been  stated  by  other  writers  on  the  subject,  to  regard  catheteriza- 
tion as  an  operative  measure.  It  should  be  constantly  borne  in 
mind  that  as  the  urethra  is  the  natural  habitat  of  organisms 
capable  of  setting  up  inflammation  when  an  opening  offers  from 
any  traumatism  that  may  occur  there  infection  is  liable  to  arise, 
hence  the  necessity  of  observing  all  possible  precautions  to  render 
the  field  and  the  instruments  sterile.  More  with  the  view  of 
refreshing  the  reader's  memory  than  from  a  desire  to  improve 
upon  the  directions  given  in  many  text-books  on  surgery  as  to  the 
manner  in  which  a  urethral  instrument  should  be  passed,  the 
following  description  is  given: 

In  order  to  properly  enter  the  bladder,  the  catheter,  bougie,  or 
sound  must,  after  the  instrument  passes  the  bulbomembranous 
junction,  correspond  in  shape  to  this  curve.  The  steel  and  some 
of  the  silk  instruments  already  mentioned  are  curved  before  using, 
following  either  the  normal  curve,  or  being  made  to  correspond 
to  any  deviation  from  the  normal  curve  of  the  urethra,  such  as 
might  be  caused  by  an  enlargement  of  the  prostate.  The  straight 
instruments,  being  flexible,  are  made  to  assume  the  proper  curve 
by  the  pressure  from  the  urethra  in  its  curved  portion.  The 
pendulous  urethra,  being  straight  from  the  meatus  to  the  bulbo- 
membranous junction,  a  straight  instrument,  if  flexible,  will 
penetrate  as  far  as  the  bulbomembranous  junction,  but  after 
this  point  is  passed,  and  we  get  beyond  into  the  remaining  por- 
tion of  the  urethra  to  the  bladder,  a  fixed  canal  is  encountered. 
This  being  the  case,  it  should  be  borne  in  mind  that  both  the 
flexible  and  the  fixed  urethra  must  be  so  dealt  with  as  to  cause 
the  least  possible  irritation,  and  also  that  the  beak  of  the  instru- 
ment, having  entered  the  bladder,  is  not  to  be  pushed  so  far  back 
into  the  bladder  as  to  cause  injury  to  the  posterior  bladder-wall. 

In  passing  a  straight  flexible  instrument,  the  field  having  been 
properly  cleansed  and  the  instrument  lubricated,  it  may  be 
introduced  with  the  patient  either  lying  down  or  standing,  the 
operator  standing  on  either  side  of  the  patient,  as  may  seem  most 
convenient.  The  instrument  is  passed  easily  in  as  far  as  the 
bulbomembranous  junction,  at  which  point,  ordinarily,  some 
slight  resistance  is  met.  Individuals  of  the  neurotic  type  are 
extremely  likely  to  exhibit  sensitive  points  in  the  anterior  ure- 


CATHETERIZATION  45 

thra,  even  if  little  or  no  organic  disturbance  exists  there.  Under 
such  circumstances  pain  will  be  considerably  lessened  by  using 
a  generous  amount  of  lubricant,  and  passing  the  instrument  ver}^ 
slowly;  by  grasping  the  glans  penis  and  extending  the  urethra, 
and  at  the  same  time  pressing  on  the  bulbomembranous  junction 
with  the  finger  over  it  on  the  perineum,  the  angle  will  become  a 
little  less  acute  where  the  pendulous  urethra  joins  the  beginning 
of  the  fixed  curved  portion  of  the  urethra,  and  the  instrument 
will  slip  more  easily  into  this  curved  portion. 

The  resistance  which  the  straight  instrument  meets  when 
passed  as  far  as  the  bulbomembranous  junction,  if  no  stricture 
exists,  may  be  owing  to  the  contraction  of  the  sphincter  urethrse 
muscle.  This  is  generally  more  pronounced  in  neurotic  persons 
and  in  those  on  whom  the  catheter  is  passed  for  the  first  time, 
and  is  again  referred  to  under  spasmodic  stricture.  In  passing  a 
straight  instrument,  by  elongating  and  depressing  the  penis,  there- 
by putting  the  urethra  on  the  stretch,  and  by  making  slight  gentle 
perineal  pressure,  this  obstruction,  if  present,  is  generally  overcome. 
Care  should  be  observed  not  to  exert  too  much  pressure,  and  that 
it  may  be  directed  properly. 

In  passing  instruments,  whether  straight  or  curved,  the  portion 
of  the  urethral  canal  most  likely  to  be  injured  is  the  floor  of  the 
urethra  at  the  bulbomembranous  junction. 

It  is  a  safe  plan,  in  using  either  a  straight  or  a  curved  instru- 
ment, to  keep  closely  to  the  roof  of  the  urethra  until  the  instru- 
ment has  entered  the  curved  portion,  pushing  it  forward  with  a 
slow  and  gliding  movement ;  it  should  be  borne  in  mind  in  every 
case,  whether  the  instrument  is  passed  by  the  operator  or  by  the 
patient  himself,  that  the  object  sought  is  to  make  the  end  of  the 
catheter  find  the  anterior  opening  of  the  fixed  portion  of  the 
urethra.  If  the  operator  loses  sight  of  this  aim,  he  may  fail  to 
find  the  opening. 

Ordinarily,  when  a  catheter,  either  straight  or  curved,  enters 
the  bladder,  this  is  evidenced  by  the  relaxation  of  the  contracted 
muscle  or  by  the  escape  of  a  small  quantity  of  urine  from  the  end 
of  the  catheter.  In  thin  subjects  this  fact  may  also  be  easily 
determined  by  placing  the  palm  of  the  hand  on  the  abdomen 
above  the  pubes,  when  the  beak  of  the  instrument  can  be  felt 


46 


GENERAL   EXAMINATION    OF    PATIENTS 


against  the  hand  if  a  curved  metal  sound  or  catheter  has  been 
used.  If  doubt  exists,  three  or  four  ounces  of  fluid  may  be  injected 
through  the  catheter  by  means  of  a  syringe.  If  the  fluid  runs  into 
the  bladder,  ordinarily  it  will  return  through  the  catheter  when  the 
latter  is  depressed.  If  it  does  not  run  out  again  through  the  cathe- 
ter on  depressing  the  penis,  it  demonstrates  that  while  the  curved 
portion  of  the  urethra  may  have  been  reached,  the  instrument  has 
not  as  yet  pushed  far  enough  along  the  urethra  to  meet  the  bladder. 
If  the  fluid  injected  is  not  returned  through  the  end  of  the  catheter 


Fig.  20. — Illuslraling  first  position  in  passing  sound  or  other  steel  instrument  into  bladder. 


when  depressed  and  does  not  remain  in  the  bladder,  but  runs  out 
of  the  meatus  along  the  side  of  the  catheter,  it  is  evidence  that  the 
curved  portion  of  the  urethra  has  not  been  passed,  and  that  the 
compressor  urethrae  muscle  has  not  yet  relaxed. 

In  passing  a  curved  instrument  the  operator  stands  at  the  side 
of  the  patient  that  is  most  convenient  to  him.  The  penis  is  grasped 
in  the  left  hand,  the  instrument  being  held  in  the  right.  The  organ 
is  put  well  on  the  stretch,  and  held  at  an  angle  of  about  45  degrees 
to  the  body.  The  operator  should  have  in  mind  that,  until  the 
bulbomembranous  junction  is  reached,  the  straight  portion  of  the 


CATHETERIZATION 


47 


curved  instrument  should  be  kept  as  nearly  parallel  with  the  body 
as  possible.  The  instrument  may,  if  it  is  more  convenient,  be  in- 
troduced with  the  upper  portion  pointing  toward  the  feet  of  the  pa- 
tient, being  rotated  down  into  the  urethra  until  it  is  parallel  with 
the  groin,  and  then  revolved  again  until  its  upper  extremity  is  paral- 
lel with  the  abdomen,  the  upper  portion  being  just  below  the  umbili- 
cus; or,  in  passing  the  instrument,  it  may  first  be  introduced  parallel 
to  the  groin,  and  then  be  brought  around  on  a  plane  parallel  to 
the  abdomen.  In  either  case  this  last  should  be  the  final  position 
before  the  attempt  is  made  to  pass  the  instrument  into  the  blad- 


Fig.  21. — Illustrating  second  position  in  passing  sound. 


der.  Figs.  20  and  21  illustrate  these  positions.  During  this  pro- 
cedure no  forcible  attempt  should  be  made  to  push  the  instrument 
into  the  urethra;  the  urethra  should,  rather,  be  pulled  up  on  the 
instrument,  put  and  kept  on  the  stretch  by  the  fingers  of  the  left 
hand,  the  thumb  and  forefinger  of  the  right  hand  holding  the  in- 
strument—not firmly,  but  as  if  they  were  balancing  it.  While  the 
catheter  is  still  so  balanced  its  curve  will  disappear  into  the  urethra 
for  four  or  five  inches,  the  urethra  having,  as  previously  directed, 
been  brought  well  up  on  the  instrument  by  the  left  hand.  The 
shaft  of  the  instrument  should,  as  was  mentioned  before,  be  kept 


48 


GENERAL    EXAMINATION    OF    PATIENTS 


parallel  to  the  abdomen,  the  left  hand  keeping  the  urethra  on 
the  stretch.  Then  raise  the  urethra,  containing  the  instrument, 
to  a  position  at  a  right  angle  with  the  patient's  body.  Next,  the 
penis,  still  kept  on  the  stretch,  should  be  brought  down  between 
the  patient's  legs  until  it  points  toward  his  feet.  The  thumb  and 
forefinger  of  the  right  hand  should,  at  the  same  time,  balance  the 
instrument,  and,  instead  of  pushing  it,  it  should  be  allowed  to 
progress  downward  by  reason  of  its  own  weight.  The  operator 
should  really  feel  with  the  beak  of  the  instrument  for  the  begin- 
ning of  the  opening  of  the  fixed  portion  of  the  urethra ;  he  should 

rarely  use  much  force 
in  pushing  the  instru- 
ment, and,  above  all, 
he  should  avoid  push- 
ing its  beak  into  the 
floor  of  the  urethra. 
At  times  slight  spasm 
of  the  compressor  ure- 
thrae  muscle  exists ; 
this  may  often  be  over- 
come, after  the  instru- 
ment has  been  brought 
over  so  that  its  beak 
points  toward  the 
place  where  the  open- 
ing of  the  fixed  part  of 
the  canal  should  be, 
by  keeping  the  handle 
well  depressed  between  the  legs  with  the  left  hand,  and  pressing 
down  on  the  abdomen  with  the  right. 

When  the  beak  of  the  instrument  has  entered  the  curved  por- 
tion of  the  urethra,  the  left  hand,  which  has  been  holding  the  penis 
and  keeping  it  on  the  stretch,  should  be  removed,  and  the  instru- 
ment grasped  at  its  upper  extremity  between  the  thumb  and 
forefinger  of  the  left  hand,  and  allowed  to  enter  the  bladder.  It 
must  be  repeated  that  little,  if  any,  downward  pressure  is  to  be 
made  when  the  instrument  is  first  moved.  From  lying  with  its 
shaft  parallel  to  the  abdomen  it  is  bfought  up  to  an  angle  and  made 


Fig.  22. — Illustrating  third  position  in  passing  sound. 


CATHETERIZATION 


49 


to  describe  an  arc,  so  that  when  it  finaUy  enters  the  bladder,  its 
upper  outer  extremity  is  descending  toward  the  toes  of  the  patient. 
During  this  procedure  it  should  constantly  be  borne  in  mind  that 
an  attempt  is  being  made  to  pass  a  curved  instrument  into  a 
curved  canal,  not  a  straight  instrument  through  a  straight  canal. 
The  operator  must  be  careful  and  diligent  in  searching  with  the 
beak  of  the  instrument  for  the  opening  in  the  fixed  canal.  In 
passing  coude  catheters,  cystoscopes,  and  dilators  with  very 
short  curves  the  necessity  for  depressing  the  penis  while  on  the 
stretch  farther  between  the  legs,  in  order  to  make  the  curved  por- 
tion enter  the  curved  portion  of  the  canal,  is  greater  than  in  the 
case  of  the  ordinar}^  instruments.     In  the  presence  of  stricture,  the 


Fig.  23. — Illustrating  fourth  position  in  passing  sound. 

expert  can  be  somewhat  more  heroic  in  his  methods  of  pushing  an 
instrument  through  the  obstruction  into  the  bladder  than  one  with 
less  experience.  In  such  cases,  however,  it  is  a  fairly  safe  rule  to 
let  the  beak  of  the  instrument  hug  the  roof  of  the  urethra  closely. 

There  is  a  general  impression  that  attempts  at  passing  a  soft- 
rubber  catheter,  whether  made  by  patient  or  by  surgeon,  can 
result  in  no  harm,  even  if  the  efforts  to  make  it  enter  the  bladder 
are  futile.  This  view  is  an  erroneous  one,  for  the  soft- rubber 
catheter  is  inclined  to  double  up  at  the  bulbomembranous  junction, 
and,  if  force  is  exerted,  may  result  in  traumatism,  which,  although 
slight,  may  be  sufficient  to  start  up  an  infective  process.  If  it  is 
found  impossible,  either  for  the  operator  or  the  patient,  to  pass  a 
4 


50  'GENERAL   EXAMINATION   OF   PATIENTS 

soft-rubber  catheter,  an  attempt  should  be  made  to  pass  either  a 
coude  catheter  or  one  of  the  flexible  olive-pointed  French  silk 
catheters. 

Occasionally,  any  difficulty  that  may  be  experienced  in  passing 
a  catheter  or  sound  with  the  patient  in  the  prone  position  may  be 
overcome  by  having  him  assume  the  erect  posture.  This  latter 
position  may  be  preferable  in  two  classes  of  patients — those  in 
whom  a  spasm  of  the  compressor  urethrae  muscle  exists,  and  those 
in  whom  a  pocket  at  the  bulbomembranous  junction  occurs. 
Some  patients,  especially  neurotics,  are  more  successful  in  passing 
the  sound  or  catheter  themselves  than  is  the  attendant,  and  ac- 
complish it  with  less  distress. 

In  those  individuals  who  have  a  pocket  at  the  bulbomembran- 
ous junction,  the  instrument,  when  its  handle  is  depressed,  seems 
to  engage  in  the  pocket  instead  of  entering  the  fixed  portion  of 
the  curved  urethra;  if,  while  the  handle  is  depressed,  the  instru- 
ment is  pulled  very  gently  slightly  outward  for  about  a  quarter 
of  an  inch,  so  that  the  beak  is  pulled  up  a  Httle  more  on  the  roof 
of  the  urethra,  and  the  handle  is  again  depressed,  the  beak  will  not 
infrequently  find  its  way  into  the  curved  canal.  Pressure  with 
the  fingers  of  the  left  hand  on  the  perineum  over  the  beak  of  the 
instrument  aids  in  such  conditions.  These  are  often  found  in  old 
men  in  whom  the  urethra  exhibits  a  tendency  to  sag  down  at  the 
bulb. 

For  descriptive  purposes,  the  methods  of  passing  the  catheter 
or  sound  may  be  divided  into  three  stages:  To  recapitulate,  in 
the  first  stage  the  instrument  is  introduced  as  far  as  the  bulbo- 
membranous junction  and  is  placed  with  its  shaft  parallel  to  the 
abdomen  and  its  upper  extremity  below  the  umbilicus;  in  the 
second  stage  it  is  brought  over  in  a  curve,  so  that  its  upper  ex- 
tremity points  toward  the  feet  of  the  patient ;  the  third  stage  repre- 
sents its  progress  through  the  prostatic  urethra  into  the  bladder. 
When  the  instrument  has  been  brought  into  such  position  that  its 
shaft  is  parallel  with  the  abdomen,  care  should  be  taken  to  see 
that,  by  stretching  the  penis,  the  urethra  is  well  pulled  up  on  the 
instrument.  This  is  particularly  necessary  with  those  inclined 
to  corpulency. 

Time  and  gentleness  are  the  two  important  factors  in  passing 


i 


THE   VALUE   OF   THE   X-RAY   IN   DIAGNOSIS  5 1 

an  instrument  through  the  urethra,  either  for  purposes  of  ex- 
amination or  to  empty  the  bladder.  Patients  who  are  obHged 
to  catheterize  themselves  will,  after  a  time,  generally  find  the 
catheter  that  is  best  adapted  to  their  needs.  We  have  previously 
stated  that,  in  these  cases,  the  soft-rubber  catheter,  of  as  small  a 
caliber  as  seems  practicable,  or  the  silk  coude  catheter,  will  be 
found  most  suitable.  The  English  silk  catheters  with  stylets,  so 
popular  in  the  past,  have  proved  dangerous  in  both  the  patient's 
and  the  practitioner's  hands,  and  have  fallen  into  disuse.  They 
possess  all  the  disadvantages  of  the  steel  instrument,  and,  besides, 
being  made  of  silk,  are  likely  to  be  handled  carelessly. 

THE  VALUE  OF  THE  X-RAY  IN  DIAGNOSIS 

Since  the  previous  edition  of  this  work  was  published  such 
rapid  advances  have  been  made  in  the  diagnostic  ability  to  diag- 
nose diseased  conditions  of  the  urinary  tract  through  the  use  of 
the  :^-ray  that  it  has  been  thought  best  to  rewrite  the  article  pub- 
lished at  that  time.  It  is  difficult  in  a  work  of  this  nature  and  scope 
to  always  allow  the  proper  amount  of  space  for  each  given  subject. 
It  is  our  desire  to  give  the  views  resulting  from  our  personal  ex- 
perience as  clearly  as  possible,  and  to  refer  inquirers  desiring  to 
study  the  subject  comprehensively  to  the  vast  amount  of  literature 
which  has  accumulated  during  the  past  three  years  on  this  matter. 
It  should  be  noted  here  that  the  personal  experience  of  men  very 
familiar  with  this  class  of  work  who  conduct  the  x-ray  laboratories 
in  the  clinics  and  hospitals  of  large  size  is  often  of  great  value  not 
only  in  giving  them  ability  to  take  a  photograph  of  the  various 
lesions,  but  also  to  translate  the  same  for  the  benefit  of  the  indi- 
vidual not  very  familiar  with  such  work.  Concerning  the  bladder, 
it  can  be  stated  that  an  :K-r ay  plate,  skilfully  taken,  will  demon- 
strate in  the  vast  majority  of  cases  very  distinctly  such  a  con- 
dition as  stone  in  the  bladder. 

Stone  in  the  ureter  can  generally  be  clearly  demonstrated,  al- 
though confusion  may  sometimes  occur  from  the  presence  of 
shadows  there,  most  often  due  to  cicatricial  conditions  occurring 
either  in  the  ureter  or  adjacent  to  it.  It  is  rarely  that  stones  in 
the  kidney  cannot  also  be  clearly  demonstrated  through  the  same 
procedure.     Efforts  are  occasionally  made  to  diagnose  such  condi- 


52  GENERAL  EXAMINATION   OP  PATIENTS 

tions  in  the  bladder  as  diverticula  of  that  organ  through  the  aid  of 
an  injection  of  a  solution  of  bismuth.  Success  in  our  limited  ex- 
perience with  this  procedure  does  not  often  occur,  but  it  is  prob- 
able that  as  we  become  more  familiar  with  the  technic  this  will 
more  often  furnish  an  aid  for  the  discovery  of  such  conditions. 
The  solutions  of  bismuth  are  apparently  unirritating  to  the  blad- 
der, although  it  is  difficult  to  entirely  wash  away  the  bismuth  im- 
mediately from  the  bladder  surfaces,  and  it  may  be  several  days 
before  the  bismuth  placed  in  the  bladder  is  entirely  eliminated. 
Ureter  catheters  coated  with  bismuth,  which  have  for  a  long  time 
been  obtainable  for  this  work,  are  of  material  aid  in  connection 
with  the  use  of  the  x'-ray  in  diagnosing  conditions  of  the  ureter  and 
to  some  extent  of  the  kidney,  particularly  as  regards  the  position 
of  this  latter  organ.  When  a  solution  of  some  metallic  substance  is 
injected  or  poured  through  such  a  catheter,  either  into  the  ureter  or 
beyond  it  into  the  kidney,  pelvis,  and  colices,  a  procedure  to  which 
the  term  "pyelography"  is  applied,  valuable  information  may  not 
infrequently  be  obtained.  At  the  present  time  it  is  wiser  to  hold 
views  of  a  conservative  nature,  both  as  regards  the  information  to 
be  obtained  from  this  procedure  and  the  inconveniences  or  dangers 
attending  it.  At  the  same  time,  as  we  look  back  and  see  how  much 
has  been  gained  in  the  line  of  diagnostic  procedure  from  the  use 
of  the  cystoscope  and  ureter  catheterization,  it  would  seem  as  if 
in  a  short  time  very  brilliant  results  should  be  obtained  through 
pyelography.  Just  at  present  the  number  of  men  who  have  ob- 
tained them  are  few.  An  excellent  book  on  the  subject  is  that  of 
W.  T.  Braasch ("Pyelography,"  W.  B.  Saunders  Co.,  1915). 

The  substances  generally  used  are  solution  of  thorium,  collargol, 
and  argyrol.  Their  value  is  probably  in  the  order  mentioned. 
The  solution  of  thorium  (a  10  per  cent,  one  being  used)  is  pre- 
pared as  follows: 

To  make  100  c.c.  of  a  10  per  cent,  solution  10  gm.  of  thorium 
nitrate  are  dissolved  in  as  little  distilled  water  as  possible;  to  this 
solution,  kept  hot  on  a  water-  or  steam-bath,  are  added  30  c.c.  of  a 
50  per  cent,  solution  of  sodium  citrate,  the  additions  being  made  in 
small  quantities  and  care  being  taken  to  shake  the  solution  thor- 
oughly after  each  addition.  At  first  after  the  addition  of  the  citrate 
solution  a  white  gummy  precipitate  is  formed,  which  later  becomes 


1 


the;  vaIvUE  of  the  x-ray  in  diagnosis 


53 


granular,  and  finally  dissolves  on  the  addition  of  all  the  citrate 
solution.  This  solution  is  then  made  neutral  to  litmus  by  the  care- 
ful addition  of  a  normal  solution  of  sodium  hydroxid,  and  made  up 
to  the  required  volume  of  loo  c.c.  with  distilled  water.  On  fil- 
tration, a  clear,  limpid  solution  is  obtained,  which,  when  sterilized, 
either  by  boiling  or  steam  under  pressure,  is  ready  for  use.  The 
stability  of  the  solution  is  not  affected  in  the  least  by  sterilization. 
We  have  endeavored  to  illustrate  (fig.  24)  in  a  single  line,  so  that 
the  eye  can  see  at  a  glance,  a  schematic  view  of  about  what  is  sup- 


Fig.  24. — I,  2,  and  3,  Normal  kidney,  pelvis,  and  calices;  4,  5,  and  7,  hydronephrotic  kidney;  6,  inflam- 
matory dilatation  due  to  stone;  8,  kidney  with  double  pelvis. 


posed  to  be  the  various  conditions  found  in  the  kidney  after  the  in- 
jection of  one  of  these  salts,  and  the  picture  is  taken.  This  schem- 
atic drawing  which  we  present  is  not  taken  directly  from  plates 
either  of  our  own  or  of  other  observers,  but  only  represents  the 
equivalent  of  what  might  be  considered  a  composite  photo- 
graph. 

The  injections  are  made  with  the  patient  in  a  prone  position,  with 
a  solution  so  liquid  that  it  will  easily  pass  through  the  lu-eter  cath- 
eter which  should  not  be  too  large  to  easily  pass  through  the  ureter. 


^  .  GENERAL   EXAMINATION   OF   PATIENTS 

It  seems  to  us  that  it  makes  little  difference  whether  the  gravity 
method  of  pouring  it  in  through  a  funnel  at  as  low  a  height  as  will 
permit  the  fluid  to  flow  is  adopted  or  whether  it  is  injected  very 
slowly  and  carefully.     Two  to  5  c.c.  of  the  solution  are  generally 
sufficient,  although  a  hydronephrotic  kidney  will  sometimes  hold 
much  more.    At  the  first  evidence  of  coHc,  injections  should  cease. 
After  the  injection  is  made,  exposure  to  the  plate  should  be  as  short 
as  practical,  and  an  effort  should  be  made  to  remove  all  the  solu- 
tion remaining  in  the  kidney.     In  a  general  way  those  who  are  very 
familiar  with  this  work  claim  that  a  normal  kidney  pelvis  and  ca- 
lices  can  be  demonstrated,  that  the  distention  due  to  a  hyperneph- 
rotic  sac  can  be  determined,  and  that  various  inflammatory  condi- 
tions which  are  more  liable  to  attack  the  calices  can  be  made  out. 
If  a  stone  is  suspected,  it  is  wiser  to  take  a  picture  to  try  to  deter- 
mine it  before  pyelography  is  attempted.    It  is  also  useful  in  show- 
ing kinks  of  the  ureter,  strictures  of  the  same,  and  malpositions  of 
the  kidney.     The  inconveniences  and  dangers  attending  this  pro- 
cedure are  as  follows: 

While  the  schematic  drawing  (see  fig.  24)  in  a  general  way  is 
supposed  to  outline  some  of  the  conditions  that  may  be  found  to 
be  present,  a  proper  interpretation  of  a  plate  may  often  only  cor- 
rectly be  made  by  a  man  well  versed  in  that  work.  Concerning 
the  dangers,  the  chief  one  seems  to  be  the  overdistention  of  the 
pelvis  of  the  kidney  and  the  forcing  of  the  solution  or  some  of  it 
into  the  parenchyma  of  the  organ,  giving  rise  to  inflammatory 
disturbances,  possibly  an  embolus.  A  very  interesting  and  scien- 
tific article  has  been  written  on  this  subject  by  M.  Mason,  M.  D., 
"Dangers  Attending  Injections  of  the  Kidney  Pelvis  for  Pyelog- 
raphy," Jour.  Amer.  Med.  Assoc,  19 14. 

It  is  the  opinion  of  some  men  who  have  done  considerable  work 
in  this  line  that  pyelography  should  only  be  attempted  after  the 
observer  has  been  unable  to  make  a  proper  diagnosis  of  existing  con- 
ditions through  other  measiu-es,  such  as  the  use  of  the  cystoscope, 
ordinary  ;c-ray  plates,  tests  for  the  permeability  of  the  kidney,  and 
similar  procedures.  While  such  a  view  may  be  correct  in  many 
cases,  it  should  be  still  borne  in  mind  that  where  operation  seems 
inevitable,  even  if  of  an  exploratory  nature,  as  a  rule  no  great  harm 


THE   VALUE    OF   THE    X-RAY   IN   DIAGNOSIS  55 

exists,  and  possibly  some  valuable  information  may  be  obtained 
through  this  measure. 

Great  care  in  mild  or  suspected  cases  of  tuberculosis  of  the  kid- 
ney should  be  exercised  in  attempting  to  inject  any  of  the  above- 
mentioned  substances  into  the  kidney  pelvis,  as  by  so  doing  a  con- 
dition necessitating  an  operation  may  be  brought  on  which  might 
otherwise  have  been  avoided. 


CHAPTER  II 

ENDOSCOPY.— CYSTOSCOPY.— CATHETERIZATION  OF 
THE  URETERS 

ENDOSCOPY 

"With  the  invention,  within  recent  years,  of  a  small  electric 
light  that  does  not  give  off  heat  and  that  can  be  placed  at  the  end 
of  a  tube  introduced  into  the  urethra,  this  method  of  making 
urethral  examinations  has  come  largely  into  favor.  The  tubes 
used  for  making  endoscopic  or  urethroscopic  examinations  are 
procurable  in  a  variety  of  lengths,  and  the  various  manufacturers 
have  projected  numerous  modifications  of  the  original.  The 
principle  of  most  of  them,  however,  is  the  same.  The  endoscope 
in  general  use  is  a  metal  tube  fitted  with  a  mandarin  for  introduc- 
tion ;  the  tube  being  inserted  into  the  urethra  to  the  desired  point, 
the  mandarin  is  removed,  and  a  tiny  electric  light  is  introduced 
on  its  groove  to  the  distal  extremity  of  the  tube. 

In  order  properly  to  examine  the  urethra  by  means  of  the  en- 
doscope the  patient  should  lie  on  a  high  table,  in  a  semirecumbent 
position,  his  legs,  from  the  knees  down,  hanging  below  the  table, 
and  rest  on  two  supports  or  chairs.  The  examiner  should  sit  on 
a  stool  at  his  feet.  The  bladder  should  be  emptied  previous  to 
examination,  and  about  one  dram  of  a  2  per  cent,  cocain  solution 
be  injected  into  the  deep  urethra.  If  the  size  of  the  meatus  will 
admit,  the  endoscopic  tube  is  easily  passed  as  far  as  the  bulbo- 
membranous  junction.  If,  when  a  more  extensive  examination 
is  demanded,  it  is  desired  to  introduce  the  tube  beyond  the  bulbo- 
membranous  junction,  it  is  necessary  to  depress  the  outer  end  of 
the  endoscope  to  a  very  marked  degree.  This  is  best  done  in  all 
cases,  especially  when  the  instrument  is  used  for  diagnostic  pur- 
poses, for  it  is  only  by  allowing  the  end  of  the  tube  to  pass  a  little 
beyond  the  bulbomembranous  junction  that  the  colliculus  can 
well  be  made  out  and  a  fair  conception  be  had  of  the  appearance 

56 


ENDOSCOPY 


57 


of  the  deep  urethra.  For  these  purposes,  and  more  especially 
for  that  first  mentioned,  a  tube  somewhat  smaller  than  that 
required  for  examining  the  pendulous  urethra  alone  should  be 
selected.  Curved  endoscopic  tubes,  though  easier  to  introduce 
into  the  posterior  urethra,  have  not,  as  a  rule,  been  found  to  be  of 
much  practical  value.  A  straight  tube,  by  being  well  depressed, 
can  be  introduced  with  comparative  ease  so  far  into  the  posterior 
urethra  that  the  colhculus,  especiahy  if  enlarged,  can  be  seen  at  the 
distal  end  of  the  tube.  When  this  is  seen,  the  tube  is  slowly 
withdrawn,  and  various  portions  of  the  urethra  from  the  colliculus 
out  can  be  examined  as  the  tube  is  removed.  Pledgets  of  cotton 
wound  on  the  end  of  long  slender  applicators  should  be  frequently 


25. — F.  C.  Valentine's  electric  endo- 
scope. 


introduced  through  the  tube  in  order  to  remove  the  constantly 
accumulating  mucus,  which  would  otherwise  obstruct  the  view. 
It  is  only  after  considerable  practice  in  the  examination  of  healthy 
urethras  by  the  endoscopic  method  that  one  becomes  thoroughly 
familiar  with  the  normal  urethral  picture.  An  endoscopic  ex- 
amination will  reveal  to  the  surgeon  the  conditions  that  exist  from 
the  colhculus  outward,  and  it  should  always  be  made  in  those 
cases  in  which  the  ordinary  treatment  for  chronic  inflammatory 
conditions  of  the  urethra  fails  to  give  good  results.  The  presence 
of  vegetations  or  of  internal  chancre  may  be  ascertained  through 
an  endoscopic  examination.  The  effect  of  treatment  may, 
if  desired,  likewise  occasionally  be  observed.  A  persistent 
localized  lesion  also  may  be  treated  by  means  of  the  endoscope 


58        ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

in  a  satisfactory  manner.  This  is  particularly  true  of  those  cases 
in  which  infection  of  the  folUcles  exists,  pus  being  easily  seen 
exuding  from  them.  For  the  treatment  of  such  conditions  as 
infected  follicles,  a  fine-pointed  galvanocautery  probe  can  be  intro- 
duced through  the  endoscope  in  a  line  vertical  to  the  base  of  the 
follicle,  which  is  then  destroyed  by  means  of  the  current.  Not 
more  than  two  or  three  follicles  should  be  destroyed  at  one  sit- 
ting, and  the  operation  should  not  be  repeated  oftener  than  once 


^""I'l"' 


Fig.  26. — Galvanocautery  point. 

a  week.  Small  knives  devised  for  the  purpose  may  be  used  to  open 
up  infected  glands  and  for  other  purposes,  such  as  the  removal 
of  vegetations. 

Applications  made  through  the  endoscope  seem  to  be  of  practi- 
cal use  in  reducing  hypertrophy  of  the  colliculus.  This  hyper- 
trophy is  frequently  accompanied  by  loss  of  sexual  vigor.  Once 
seen  through  the  endoscope,  the  colliculus  is  easily  recognized 


Fig.  27. — KoUmann's  probe 


subsequently.     It  projects,  as  a  small  pillar,  from  the 

bottom  of  the  urethra  into  the  endoscopic  field,  and 

in  color  and  appearance  somewhat  resembles  a  small 

preserved    mushroom.      When    hypertrophied,  the 

mound  appears  much  higher.     This  hypertrophy  may  be  reduced 

and  the  sexual  tone  restored  by  applying  a  strong  solution  of  silver 

nitrate  (from  30  to  60  grains  to  the  ounce)  for  a  moment  on  a  pledget 

of  cotton  to  the  colliculus.    This  method  of  treatment  has  also  been 

recommended  by  some  German  writers  as  an  excellent  one  for  the 

reUef  of  neurasthenia  of  urethral  origin. 

Most  of  the  endoscopes  for  sale  in  this  country  have  a  tube 
that  is  cut  off  straight  at  its  lower  end.  A  much  better  field  for 
observation  is  obtained  through  an  endoscope  having  the  tube 


DESCRIPTION  OF  PLATE  I 

Endoscopic  Appearances 

jrjjr.  ]. — Normal  api>earance  of  the  verumontanum  at  the  point  of  its  greatest 

size  (Luys). 
Fig.  2. — Hyi)ertrophied  verumontanum. 
Fig.  3. — Xornial  appearance  of  the  urethral  bulb.     The  central  opening  takes 

the  form  of  a  vertical  slit  (Luys). 
Fig.  4. — Normal  \'-shaped  appearance  of  a  large  lacuna  of  Morgagni  (Luys). 
Fig  5 — Sc)ft  infiltration  of  the  bulbar  region.     The  swollen  masses  of  mucous 

membrane  present  the  appearance  of  hemorrhoids  (Luys). 
l"ig.  6. — Stricture  of  the  urethra.     The  mucous  membrane  is  stiffened  by  the 

growth  (jf  fibrous  tissue  and  has  lost  all  suppleness.      It  presents  a  funnel 

sha])ed  appearance  (Luys). 
Fig.  7. — Glands  of  Littre  with  purulent  contents. 
Fig.  8. — .\n  enormous  cystic  gland  of  Littre  which  W(Jiilii   be  easily  ruptured 

bv  forcible  dilatations  (Luys). 


PLATE  I 


Fig.  1. 


Vis.  2. 


i'iiC.  3. 


Fig.  4. 


Fig:.  5. 


Fis.  6. 


Fig.  7. 


Fig.  8. 


ENDOSCOPY  59 

cut  off  at  an  angle  at  its  lower  end,  as  shown  in  the  illustration. 
Several  years  ago  Dr.  W.  K.  Otis,  of  New  York,  devised  an  endo- 
scope having  the  light  at  its  outer  end,  the  Hght  being  reflected  into 
the  tube.  Recently  he  devised  another,  based  on  the  same 
principle  as  the  first,  but  by  which  a  much  better  illumination  is 
afforded.  The  advantage  of  having  the  hght  at  the  outer  orifice  is 
that  the  light  and  its  carrier  do  not  infringe  on  the  lumen  of  the 
tube,  and  thus  applications  are  more  easily  made  through  it. 

It  can  easily  be  seen  how  valuable,  under  certain  conditions, 
treatment  through  the  endoscope  may  be.  At  the  same  time 
it  is  well  to  remember  that  most  of  the  obstinate  or  serious  inflam- 
matory urethral  conditions  are  situated  in  the  deep  urethra,  and 
although  such  conditions  as  infected  follicles  in  the  pendulous 
urethra  may  be  treated  individually,  any  existing  inflammatory 
condition  situated  further  along  the  urethral  tract  must  not  be 
neglected.  In  other  words,  no  good  results  will  follow  the  treat- 
ment of  the  minor  lesions  if  the  more  serious  ones  are  overlooked. 
George  Luys  has  written  a  very  interesting  book  on  the  practical 
use  of  the  endoscope.^ 

There  are  certain  things  that  should  be  remembered  by  those 
who  attempt  practical  work  with  the  endoscope.  The  two 
things  to  be  especially  noticed  in  the  endoscopic  picture  are  the 
central  figure  and  the  mucous  surface.  The  central  figure  or  win- 
dow varies  according  to  the  location  of  the  endoscope  in  the  urethra. 
In  the  glans  the  central  figure  is  a  httle  oval,  perpendicular  at  the 
pendulous  portion,  Hke  a  point  at  the  bulb,  Kke  a  vertical  window 
at  the  verumontanum,  crescent-shaped  in  the  prostatic  urethra. 
The  mucous  surface  varies  in  its  appearance  normally,  as  regards 
its  folds  and  striations,  according  to  the  size  of  tube  used  and  the 
pressure.  It  and  the  shape  of  the  central  figure  as  well  are 
changed  by  disease.  As  an  illustration,  in  soft  infiltration  the 
longitudinal  folds  are  changed,  diminished  in  number,  and  the 
striations  lost  in  the  tumefactions,  while  the  central  figure  is 
shortened.  This  condition  is  most  apt  to  be  found  in  what  may 
be  termed  beginning  chronic  urethritis. 

In  hard  infiltration  as  may  be  supposed,  the  color  is  paler,  the 
striations  may  have  disappeared,  the  window  opening  gives  more 
^  "Endoscopic  de  I'uretre  et  de  la  vessie,"  Paris,  1904. 


6o         ENDOSCOPY. CYSTOSCOPY. URETER   CATHETERIZATION 

the  appearance  of  an  opening  into  a  funnel,  and  the  whole  condition 
of  the  urethral  wall  has  become  inelastic.  This  condition  of  hard 
infiltration  is  what  is  met  with  in  true  stricture,  and  is  due  to  the 
formation  of  connective-tissue  fibers.  The  glands  of  Littre  and 
the  lacunae  of  Morgagni  are  apt  to  become  cystic  through  the  effect 
of  this  connective-tissue  formation ;  their  mouths  may  be  open  and 
swollen,  surrounded  by  inflammatory  zones,  or  closed  by  the 
fibrous  tissue,  and  the  cyst  thereby  become  subepithelial.  These 
two  conditions  of  hard  and  soft  infiltration  naturally  merge  the 
one  into  the  other  and  are  not  generally  seen  as  two  distinct  entities. 

A  field  of  vision  of  different  form  is  obtained  by  the  use  of  the 
urethroscope,  in  which  the  urethra  is  distended  either  by  means  of 
air  or  of  water.  Of  the  former  type,  an  instrument  has  been  de- 
vised by  Dr.  G.  Greenberg  and  manufactured  by  Kny-Scherer  Co., 
of  New  York.  Of  the  latter  type,  in  which  the  urethra  is  distended 
by  water,  the  Goldsmith  "irrigation  urethrocystoscope"  may  be 
found  useful.  The  use  of  this  instrument  in  the  hands  of  one  of 
our  assistants  has  given  good  results.  The  field  exposed  is  that  of 
a  flat  wall  instead  of  a  small  circular  field  as  exhibited  by  the 
ordinary  instrument. 

A  practical  way  to  thoroughly  examine  the  urethra  when  such 
ah  examination  is  required  is  to  use  this  latter  instrument  first, 
but  any  diagnosis  arrived  at  should  be  confirmed  through  the  use 
of  a  plain  tube  later. 

CYSTOSCOPY 

The  illumination  and  inspection  of  the  human  bladder  by 
means  of  the  cystoscope  furnish  a  means  of  diagnosing  diseases  of 
that  viscus.     The  history  of  cystoscopy  dates  back  to  1807,  when 


Fig.  28.— Nitze's  cystoscope  for  observation  of  bladder. 

a  German  physician,  Dr.  Bozzini,  pubHshed  an  article  on  "The 
Dight  Contractor,  or  a  Description  of  a  Simple  Contrivance  for 


CYSTOSCOPY  6 1 

Illuminating  the  Internal  Cavities  of  the  Human  Body."  His 
instrument,  as  illustrated  in  the  article  just  named,  consisted 
chiefly  of  the  chamber  that  contained  the  light,  and  of  various  light 
conductors,  shaped  for  use  in  different  organs.  His  object  was  to 
throw  the  light  through  the  conductor  into  the  various  cavities, 
and  reflect  from  its  wall  into  the  observer's  eye.  The  instrument 
did  not  receive  general  recognition,  but  it  certainly  marked  the 
beginning  of  the  many  well-developed  cystoscopic  methods  of  the 
present  day.  Next  along  this  line  of  invention  came  the  "  Specu- 
lum Urethro-cysticum,"  devised  by  Dr.  Sagalas,  and  presented 
to  the  French  Academy  of  Medicine  in  1826.  In  1853  Dr.  Desor- 
maux  brought  his  endoscope,  a  modification  of  the  foregoing  instru- 
ment, to  the  attention  of  the  Academic  de  Medecine  of  Paris.  Later 
Dr.  Bruck,  a  German  dentist,  examined  the  bladder  by  means  of 
a  tube  introduced  into  it  through  the  urethra,  and  a  strong,  white- 
hot  platinum  wire  in  the  rectum,  controlling  the  heat  produced 
by  this  wire  by  means  of  a  continuous  circulation  of  cold  water 
around  it.  Through  this  tube  he  was  able  to  inspect  the  highly 
illuminated  interior  of  the  bladder. 

The  first  actual  cystoscope,  however,  was  that  evolved  by  the 
late  Dr.  Max  Nitze,  aided  by  Joseph  Leiter,  a  well-known  in- 
strument-maker of  Vienna.  Dr.  Nitze  presented  his  instrument 
to  the  Society  of  Physicians  in  Vienna  in  1879;  he  later  added 
improvements,  to  ,it,  the  outcome  being  the  irrigating  cystoscope 
and  the  various  catheterizing  and  operating  instruments  that 
are  in  use  at  the  present  day.  All  his  are  prism  or  indirect 
cystoscopes. 

Since  the  introduction  of  Dr.  Nitze's  instrument,  many  modi- 
fications of  it  have  been  devised  by  operators  in  various  parts 
of  the  world.  Chief  among  them  are  the  straight  cystoscope 
and  the  air  cystoscope.  These  are  constructed  on  the  same 
principle  as  the  Nitze  instrument,  but  each  has  some  peculiar 
advantage  of  its  own. 

An  examining  cystoscope,  to  be  a  good  one,  should  fulfil  several 
requirements.  It  should  present  as  large  a  visual  field  as  pos- 
sible. It  should  be  of  a  caHber  not  too  large  to  pass  easily  through 
the  urethra,  and  it  should,  if  possible,  be  of  such  shape  as  to 
permit  practically   the  entire  bladder- wall   to  be  examined.     A 


62         ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

complete  examination  of  the  bladder  cannot  be  made  by  any 
examining  cystoscope  which  is  at  present  on  the  market.  Of 
any  single  instrument,  the  most  satisfactory  one  for  purposes  of 
examination  of  the  bladder  in  the  hands  of  the  writers  is  the 
original  Nitze  examining  cystoscope.  Unfortunately,  there  are 
certain  portions  of  the  bladder  wall  which  cannot  be  examined 
by  any  instrument  with  a  prismatic  lens,  such  as  is  used  in  the 
Nitze  instrument.  Parts  of  the  anterior  bladder  wall,  part 
of  its  posterior  wall,  and  part  of  the  neck  of  the  bladder  cannot 
be  carefully  inspected  through  this  instrument.  Therefore,  in 
order  to  make  the  examination  of  the  bladder  wall  absolutely 
complete,  it  is  necessary  for  the  examiner  to  have  a  series  of 
instruments  by  which  all  the  posterior  wall  can  be  seen,  and 
for   this  purpose  a  straight  view  instrument  is  indicated;  and 


Fig.  29. — Showing  field  in  Nitze's  exploring  cystoscope  (Berger  and  Hartmann). 

to  entirely  examine  the  anterior  wall  of  the  bladder  and  the  neck 
of  the  bladder,  particularly  any  pouch  which  may  underly  an 
enlarged  prostate,  an  instrument  giving  a  retrospective  view 
is  necessary.  Dr.  Schlaginweit,  a  pupil  of  Nitze's,  designed 
the  original  retrospective  instrument,  which  is  for  sale  and  used 
to  some  extent  in  this  country.     It  can  be  seen,  therefore,  that 


CYSTOSCOPY  63 

it  is  necessary  to  have  three  different  instruments  in  order  to  be 
absolutely  sure  that  every  portion  of  the  bladder  wall  has  been 
examined.  Though  a  fair  general  idea  of  the  bladder  can  be  ob- 
tained from  the  examining  Nitze,  and  an  idea  as  to  whether  or 
not  an  enlarged  prostate  exists,  a  complete  examination  is  neces- 
sary when  there  is  a  question  as  to  whether  or  not  any  tumors 
may  be  present,  as  there  frequently  is  around  the  neck  of  the 
bladder,  or  such  a  condition  as  stone  lying  underneath  an  en- 
larged prostate,  which  not  infrequently  happens,  other  instru- 
ment or  instruments  will  be  required. 

To  obviate  the  trouble  and  expense  connected  with  having 
a  number  of  separate  instruments  made  by  different  manufac- 
turers several  so-called  "universal"  cystoscopes  have  been  de- 
vised in  which,  through  the  introduction  of  various  shaped  lenses 
and  mirrors,  through  the  same  sheath,  the  entire  interior  of  the 
bladder  may  be  viewed.  These  instruments  resemble  one  an- 
other to  a  very  great  extent,  and  the  difference  between  them 
consists  mainly  in  slight  changes  in  regard  to  curve,  various 
modifications  of  the  prisms  and  of  the  mechanism.  The  Wappler 
Mfg.  Co,  have  recently  made  one  of  this  type  at  the  suggestion 
of  my  associate.  Dr.  S.  W.  Schapira,  which  has  been  used  by 
one  of  us,  and  is  apparently  useful  in  fulfilling  the  various  indi- 
cations outlined  above.  Through  a  common  sheath  can  be  intro- 
duced a  lens  for  the  indirect  examination,  for  the  direct  ex- 
amination, for  catheterization  of  the  ureters  by  the  ether  method, 
and  for  the  retrospective,  as  well  as  one  containing  a  stone 
crusher  associated  with  the  lens,  and  one  through  which  minor 
operative  procedures  may  be  carried  on  under  observation.  A 
rubber  bulb  attachment  permits  of  the  bladders  being  inflated 
with  air  instead  of  a  fluid;  this  is  sometimes  of  use  when  such  a 
condition  as  tuberculosis  of  the  bladder  is  present. 

Practical  Cystoscopy 

Position  of  Patient. — For  examination  of  the  bladder,  the  pa- 
tient may  be  placed  flat  on  the  back  in  the  lithotomy  position, 
the  illustrations  below  (p.  65)  showing  the  proper  supports  and 
correct  angle  of  legs  to  body. 

The  genitals  are  then  cleansed,  and  a  sterilized  catheter  is  in- 


64        I^NDOSCOPY.^ — CYSTOSCOPY. — URETER   CATHETERIZATION 

serted  into  the  bladder.  The  contents  of  the  bladder  are  evacuated, 
and  if  the  urine  is  not  clear,  the  bladder  is  washed  repeatedly 
until  the  fluid  comes  away  clear;  the  viscus  is  then  filled  with  a 
2  per  cent,  boric-acid  solution  and  the  catheter  withdrawn. 

The  proper  instrument  having  been  chosen,  the  light  of  the 
cystoscope  is  adjusted,  and  the  instrument  intended  for  inspec- 
tion is  well  lubricated  and  inserted  into  the  bladder;  the  light  is 
turned  on,  and  if  the  prism  instrument  is  used,  through  rota- 
tion the  anterior  wall  of  the  bladder,  the  roof,  the  floor,  and 
the  sides  of  the  bladder  are  examined  as  thoroughly  as  the  shape 
of  the  instrument  will  permit.  Bearing  in  mind  what  has  been 
said  about  the  limitations  of  view  through  the  various  shaped 
cystoscopes,   if   it   seems   required   on   its   withdrawal,    a   cysto- 


Fig.  30. — The  Nitze  operating  cystoscope. 


scope  of  another  shape  should  then  be  introduced  in  order  to 
make  the  examination  as  thorough  as  possible.  By  practice 
through  the  use  of  the  artificial  so-called  phantom  bladders, 
at  present  being  sold  by  the  surgical  instrument  houses,  some 
familiarity  with  the  use  of  the  cystoscope  can  be  obtained  by 
the  beginner,  and  they  will  be  found  useful  for  that  purpose  to  a 
considerable  degree.  In  examining  the  bladder  the  importance 
of  method  need  hardly  be  insisted  upon  in  order  that  no  part  of 
the  mucous  membrane  may  unnecessarily  be  overlooked. 

Very  interesting  are   the  views  obtained  of   the  neck  of  the 


CYSTOSCOPY 


65 


bladder  through  the  retrospective  lens.  When  the  retrospective 
CYStoscope  is  pushed  toward  the  neck  of  the  bladder,  the  urethra, 
looking  through,  it  appears  as  a  slit.     As  the  cystoscope  is  pulled 


Fig.  31. — Table  showing  BierhofE  supports  for  legs  in  cystoscopy. 


Fig.  32.— Position  for  cystoscopy. 


forward  and  the  retrospective  appliance  is  brought  nearer  to  the 
neck  of  the  bladder,  the  urethral  orifice  appears  enlarged,  and 

5 


66        ENDOSCOPY. — CYSTOSCOPY. — URETER    CATHETERIZATION 

the  cystoscopic  tube  itself  can  be  seen,  as  shown  in  our  illus- 
tration. 

Cystoscopic  Appearances. — Acute.  Cystitis. — The  picture  varies 
according  to  the  degree  of  inflammation  present.  A  general  hy- 
peremia condition  is  noticed,  most  marked  at  neck  of  bladder 
with  dilated  blood-vessels. 

Chronic  Cystitis. — The  mucous  membrane  may  be  pale  or  dark 
gray,  and  the  bladder  folds  so  thickened  that  if  the  thickened 
condition  is  localized,  it  may  at  times  be  dijfferentiated  with  diffi- 
culty from  a  tumor. 

Non-tubercular  Ulcerative  Cystitis. — This  may  be  due  to  the 
ingestion  of  certain  drugs  or  to  repeated  attacks  of  cystitis,  and 
occurs  most  often  in  women.  It  is  present  only  in  rare  grave 
forms  of  vesical  disease.  The  bladder  is  always  very  irritable, 
and  will  rarely  hold  more  than  one  ounce  of  fluid.  One  or  more 
characteristic  ulcers  may  be  seen  on  an  otherwise  perfectly  healthy 
mucous  membrane. 

Tubercular  Cystitis. — In  this  condition  the  cystoscope  reveals 
localized  hyperemia  spots  of  vesical  mucous  membrane,  with 
distinct  tubercles. 

There  may  also  be  distinct  tubercular  ulcerations,  the  edges  of 
which  are  somewhat  elevated,  in  contradistinction  to  those  of  the 
ordinary  cystic  ulcer. 

Syphilis  of  the  Bladder. — It  has  been  known  for  several  years 
that  syphilis  occasionally  attacks  the  walls  of  the  bladder.  In 
earlier  editions  of  this  work  it  was  stated  that  we  had  noticed  that 
contracted  bladder  with  chronic  cystitis  was  not  infrequently 
associated  with  a  syphilitic  history,  and  that  proper  antisyphilitic 
constitutional  treatment  was  a  great  aid  to  the  local  measures 
instituted. 

Two  procedures  developed  within  the  past  few  years  have  been 
very  valuable  diagnostic  aids  for  the  recognition  of  these  lesions — 
the  more  common  use  of  the  cystoscope  and  the  Wassermann 
reaction. 

Syphilis  is  most  often  found  attacking  the  bladder  in  the  later 
rather  than  the  earlier  manifestations  of  the  disease.  Syphilitic 
lesions  may  be  mistaken  either  for  tuberculosis  or  for  papilloma  of 
the  bladder.     They  usually  consist  of  deep  or  shallow  ulcerations, 


DESCRIPTION  OF  PLATE  II 
Cystoscopic  Appearances 

Fig.  1. — Mouth  of  ureter. 

Fig.  2. — Right  ureteral  papilla  and  mouth  of  ureter. 

Fig.  3. — Showing  ureteral  opening  and  papilloma. 

Fig.  4. — A  jet  of  bloody  urine  burst  from  the  tiny  opening. 

Fig.  5. — Pus  discharging  from  ureter. 

Fig.  6. — Tubercular  cystitis ;  primary  stage.  Numerous  minute  ecchymoses 
surrounded  by  a  hyperemic  spot ;  many  ramified  vessels. 

Fig.  7. — Marked  bilateral  hypertrophy  of  the  prostate — trabecular  bladder. 

Fig.  8. — Partial  hypertrophy  of  the  prostate.  Enlarged  median  lobe  project- 
ing into  the  bladder. 


PLATE  II 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


Fig.  6. 


Fig.  7. 


Fig.  8. 


PLATE  III 


Fig. 


9. — Encysted   multiple   stones 
— four  only  are  shown. 


Fis 


10. — Trabecular    bladder;    di- 
verticulum of  lateral  wall. 


Fig.  11. — Pin  fixed  in  the  ante- 
rior wall  of  the  bladder  near  its 
vertex;  shadow  on  the  opposite 
wall. 


Fig.  12. — Silk  ligature  adherent 
to  the  wall  of  the  bladder,  near 
its  vertex;  shadow  on  the  opposite 
wall 


Fig.  13. — Two  fragments  of  stone 
which  remained  in  the  bladder 
after  lithotrity;  in  the  larger  one 
the  nucleus  of  uric  acid  is  seen. 


Fig.  14.- 


-Catheter  covered  by  urine 
concretions. 


Cystoscopic  Appearaxces 


PLATE  IV 


Fig.    15. — Catheter    doubled    upon  Fig.      16.  —  Cauliflower     tumor     of 

itself.  bladder. 


Fig.  17. — Villous  epithelioma. 


Fig.   18. — Cancerous    sessile    tumor 
of  the  bladder 


Fig.    19.  —  Lobulated    epithelioma.  Fig.  20. — Tumor  of  bladder. 


Fig.  2 1 . — Small  smooth  tumor  with  long  pedicle. 
Cystoscopic  Appearances 


CYSTOSCOPY  67 

single  or  numerous,  but  gumma  may  often  give  rise  to  tumor  for- 
mations which  are  not  infrequently  pediculated. 


Fig.  33. — Syphilitic  ulceration  of  the  bladder. 

An  exhaustive  and  scientific  article  on  this  condition  has  been 
written  by  G.  Gayet  et  E.  Favre  (Journal  d'Urologie,  July,  19 14). 


Fig.  34. — Syphilitic  ulceration  of  the  bladder. 


Now  that  syphilis  of  the  bladder  is  being  diagnosed  with  increas- 
ing frequency  its  importance  is  becoming  manifest  in  two  different 


68         ENDOSCOPY. — CYSTOSCOPY. — URETER    CATHETERIZATION 

directions.  One  is  that  when  diagnosed  it  may  often  direct  the 
proper  treatment  of  conditions  such  as  myelitis,  locomotor  ataxia, 
and  generally  the  late  lesions  of  the  nervous  system  associated  with 
syphilis.  The  indication  is,  of  course,  for  active  antisyphilitic 
together  with  such  appropriate  local  treatment  as  irrigations  or 
astringent  appHcations  as  may  suggest  themselves  to  the  surgeon. 
Because  gummata  of  the  bladder  have  a  tendency  to  take  on 
tumor-like  formations,  it  is  important  that  a  very  careful  inquiry 
should  be  made  into  the  history  and  serology  of  all  individuals 
with  tumor  of  the  bladder,  and  in  questionable  cases  the  thera- 
peutic test  thould  be  instituted  in  addition. 


Fig.  35. — Syphilitic  gumma  of  the  bladder. 

Foreign  Bodies  in  the  Bladder. — Foreign  substances  that  cannot 
be  detected  by  the  sound,  even  in  the  hands  of  an  experienced 
surgeon,  may  be  easily  seen  and  localized  by  means  of  the  cysto- 
scopy 

Stone  in  the  Bladder. — The  cystoscope  plainly  reveals  stones  in 
the  bladder,  the  observer  being  thus  able  to  determine  their  size, 
shape,  and  mobility,  and  to  percuss  them  with  the  beak  of  the 
cystoscope,  guided  by  his  eye. 

Tumors  in  the  Bladder. — It  is  in  tumors  of  the  bladder  that  the 
cystoscope  finds  its  greatest  field  of  usefulness,  the  presence  of 
such  growths  being  generally  clearly  detectable  by  its  use,  the 


CYSTOSCOPY  69 

isolated  tumors  being  more  distinct  than  those  made  up  of  diffuse 
vegetations. 

Enlargement  of  the  Prostate. — Enlargement  of  the  prostate 
can  be  diagnosed  through  the  use  of  tbe  cystoscope  in  some 
cases  where  it  is  extremely  difficult  to  make  a  correct  diagnosis 
of  its  existence  through  the  other  methods  at  the  examiner's 
disposal.  This  is  particularly  true  of  those  cases  in  which  the 
principal  part  of  the  enlargement  juts  forward  into  the  bladder 
and  the  rectal  examination  is  of  little  aid.  The  folds  of  the 
trigone  which  come  into  view  on  the  reversal  of  the  prism  in- 
strument in  the  normal  prostate  show  no  inequality,  while  in 
enlargement  of  the  prostate  the  folds  give  a  shadow  show- 
ing an  unsymmetric  enlargement,  or  an  enlargement  in  the 
depression  between  the  folds  showing  the  presence  of  the  third 
lobe.  The  study  of  the  picture  showing  normal  prostatic  appear- 
ance, together  with  that  of  Figs.  7  and  8  of  the  cystoscopic  plate 
(Plate  II),  will  make  the  writers'  meaning  clearer. 

Ordinarily,  the  exploring  cystoscope  should  not  remain  in  the 
bladder  for  more  than  fifteen  minutes  without  the  light  being 
turned  off ;  care  should  also  be  taken  to  see  that  the  lamps  do  not 
become  too  hot,  that  the  amount  of  fluid  is  not  too  slight,  and 
that  the  cystoscope  is  not  pulled  too  far  forward  lest  the  neck 
of  the  bladder'be  injured. 

It  may  be  well  here  to  repeat  the  statement  made  in  describing 
the  use  of  the  endoscope,  namely,  that,  like  this  latter  instrument, 
the  exploring  cystoscope  may  lend  great  aid  in  making  a  diagnosis, 
but  before  he  attempts  to  diagnose  diseased  conditions  by  its  aid, 
the  examiner  should,  if  possible,  famiHarize  himself  with  the  ap- 
pearance of  the  normal  bladder. 

Cystoscopic  diagnosis  is  not  always  easily  made,  much  patience 
and  considerable  experience  being  necessary  to  avoid  error.  By 
its  means  a  typical  growth  or  a  gHstening  stone  is  readily  recog- 
nized, but  the  inexperienced  cystoscopist  will  frequently  be  misled 
and  perplexed  by  the  appearance  which  the  mucous  membrane 
is  wont  to  assume  under  the  varying  conditions  of  infiltration, 
relaxation,  extravasation,  and  congestion.  He  may  often,  under 
the  mistaken  behef  that  he  is  deahng  with  a  new-growth,  be 
tempted  to  interfere  operatively,  to  his  patient's  detriment. 


70        ENDOSCOPY.— CYSTOSCOPY. — URETER   CATHETERIZATION 

INSTRUMENTAL  EXAMINATION  OF  THE  KIDNEY 
Within  the  past  few  years  much  reliable  scientific  work  has 
been  done  to  show  the  condition  of  each  kidney,  by  collecting  the 
secretion  of  each  of  these  organs  separately.  Many  new  tests, 
such  as  the  phloridzin  and  the  methylene-blue,  have  been  ex- 
ploited to  show  the  permeability  of  the  kidney,  and  much  has  been 
done,  particularly  abroad,  to  show  the  normal  amount  of  the  uri- 
nary constituents  by  such  methods  as  cryoscopy.  These  methods, 
together  with  the  examination  of  the  blood,  and  particularly  of 
the  blood  chemistry,  have  greatly  increased  our  facilities  for  esti- 
mating more  accurately  the  total  amount  of  work  done  by  each 
or  by  both  kidneys.  Of  late  it  has  become  more  and  more  the 
custom  to  decry  the  aid  furnished  by  the  presence  or  absence  of 
albumin  or  casts  in  diagnosing  disease  of  the  kidney.  The  writers 
believe  that  their  presence  or  absence  is  often  of  small  diagnostic 
value,  and  attaches  more  importance  in  many  cases  to  the  test  for 
kidney  permeabiHty  and  to  the  information  derived  from  ureter 
catheterization  as  showing  the  condition  of  these  organs.  The 
methods  that  will  be  considered  in  detail  here  are  those  that  practi- 
cal experience  has  proved  to  be  of  value — that  can  be  commended 
from  personal  observation ;  those  measures  that  have  been  found 
to  be  impracticable  or  unsuitable  for  general  work  will  not  be 
exhaustively  considered. 

Catheterization  of  the  Ureters 
By   persistent   efforts    during   the   past   ten   years,   and  more 
particularly  during  the  past  three^  a  few  men,  to  whom  great 


Fig.  36.— Bierhoff's  cystoscope  for  the  simultaneous  catheterization  of  both  ureters. 

credit  is  due,  have  given  the  practice  of  catheterizing  the  ureters 
by  means  of  ureteral  catheter  cystoscopes  so  great  a  stimulus  that 


INSTRUMENTAL   EXAMINATION   OF   THE   KIDNEY 


71 


the  operation  is  now  performed  successfully  in  a  large  number  of 
cases.     Undoubtedly  the  modifications  and  variety  of  forms  of 


Fig-  37- — Bransford  Lewis'  double  male  ureter-cystoscope. 


the  instrument  have  played  a  part  in  the  increased  facility  with 
which  ureteral  catheterization  can  now  be  performed — the  im- 
provements in  lights,  in  lenses,  and,  above  all,  in  its  skilful  appli- 
cation have  helped  considerably  to  make  it  a  success. 

Roughly  speaking,  catheterizing  ureter-cystoscopes  are  of  two 
types — the  straight,  of  which  the  Brenner  cystoscope  is  a  type, 
and  the  concave 
or  reverse  type, 
represented  by  the 
Nitze  or  Albarran 
cystoscope.  For 
the  purpose  of  ure- 


Fig.  38. — Bransford  Lewis'  dilating  bulb. 


teral    catheterization   we   personally   prefer   the 

straight  type,  and  recommend  the  instrument  made 

by  the  Wappler  Manufacturing  Co. ,  of  New  York, 

called  the  F.  Tilden  Brown  modification  of  the 

Brenner  cystoscope.     Of  the  concave  or  reverse 

type,  the  cystoscope  made  by  the  Kny-Scheerer 

Co.,  and  called  the  Bierhoff  modification  of  the 

Nitze- Albarran  cystoscope,  is  to  be  recommended. 

There  are  many  other  similar  instruments  on  the  markets,  in  both 

this  country  and  Europe,  that  may  excel  in  some  one  particular  or 

be  superior  to  those  just  mentioned,  but  the  writers  are  unfamiliar 

with  them,  and  believe  that  each  of  the  two  recommended  is  a  good 

representative  of  its  class,  or  the  possessor  of  a  Universal  cystoscope 

of  the  type  previously  mentioned  can,  through  a  common  sheath. 

use  the  lens  most  suitable  for  the  particular  bladder,  the  ureters  of 


72         ENDOSCOPY. — CYSTOSCOPY. — URETER    CATHETERIZATION 

which  are  to  be  catheterized.  As  has  been  stated,  for  the  mere 
purpose  of  locating  the  ureters  and  catheterizing  them,  the  straight 
type  of  cystoscope  is  to  be  preferred;  but  it  would  be  very  difficult 
to  examine  the  roof  and  the  anterior  walls  of  the  bladder  with  a 
straight  instrument  if  the  bladder  were  distended.  It  has  also 
been  found,  by  practical  experience,  rather  difficult  to  find  the 
mouth  of  the  ureter  with  a  straight  instrument  when,  as  occa- 
sionally happens,  the  orifice  is  situated  high  up  along  the  bladder- 
wall  instead  of  in  its  usual  place  along  the  border  of  the  trigone; 
while  with  the  reverse  type  it  is  impossible  to  examine  the  posterior 
wall  of  the  bladder. 

Many  of  the  ureteral  catheter  cystoscopes  that  are  manufactured 
at  the  present  time  are  recommended  for  use  as  ordinary  cysto- 
scopes for  examination  of  the  bladder- walls,  as  well  as  for  catheter- 
izing the  ureters.  For  this  purpose  the  concave  is  ordinarily  pre- 
ferable to  the  straight  type,  since  through  it  the  roof  and  the  walls 
of  the  bladder,  with  the  exception  of  the  posterior  one,  may  more 
easily  be  seen.  The  general  practitioner  will  find  it  well  to  purchase 
a  good  instrument  of  each  of  the  above-mentioned  types.  Once  in 
possession  of  these,  the  ordinary  exploring  bladder  cystoscope,  used 
simply  for  examining  the  bladder-walls,  is  unnecessary.  If,  how- 
ever, an  instrument  for  that  purpose  is  desired,  the  simple  bladder- 
exploring  cystoscope  previously  mentioned  can  be  recommended. 
These  cystoscopes  have  so  small  a  shaft  that  they  can  be  introduced 
very  easily  into  the  bladder  through  a  urethra  of  comparatively 
narrow  caliber  without  causing  pain,  and,  consequently,  by  their 
use,  the  patient  is  less  likely  to  become  frightened.  It  is  some- 
times necessary,  in  order  to  obtain  a  correct  conception  of  the 
position  and  appearance  of  the  mouths  of  the  ureters,  to  use  the 
ordinary  exploring  cystoscope  before  employing  the  ureteral 
catheter  cystoscope.  Then,  too,  something  is  accomplished  by 
accustoming  the  patient  to  the  use  of  the  cystoscope,  particularly 
if  the  examiner  believes  that  the  ureters  are  to  be  catheterized 
more  than  once.  For  this  purpose,  also,  the  preliminary  use  of 
the  ordinary  exploring  cystoscope  is  to  be  recommended. 

How  to  Catheterize  the  Ureters  with  the  Ureteral  Catheter  Cyst- 
oscope of  the  Straight  Type. — So  long  as  the  operator  is  not  thor- 
oughly familiar  with  the  method  of  catheterizing  the  ureters,  as 


INSTRUMENTAL,  EXAMINATION   OF   THE   KIDNEY  73 

well  as  for  descriptive  purposes,  the  bladder  may,  for  practical 
purposes  in  using  the  catheter,  be  considered  not  exactly  as  a 
modification  of  a  round  body,  but  as  a  dome- shaped  organ,  having 
a  bottom  inclined  to  be  flat  and  triangular  in  shape.  This  triangle 
is  represented  by  the  folds  of  the  trigone  on  each  side,  while  the 
prostate  represents  the  apex. 

One  very  important  point  that  should  be  constantly  borne  in 
mind  in  using  a  catheter  cystoscope  of  the  straight  type  is  that  the 
instrument  should  never  be  rotated  when  it  is  desired  to  catheterize 
the  ureters ;  rotation,  in  the  observation  of  the  writers,  is  perhaps 
the  most  common  of  all  errors  made  by  those  who  first  attempt 
to  catheterize  the  ureters  with  this  cystoscope.  The  instrument 
should  be  used  more  as  a  lever.  Always  remember  that  the  top 
of  the  beak  should  point  toward  the  top  of  the  bladder.  An- 
other important  point  that  should  be  borne  in  mind  is  the  part 
played  by  bladder  folds.  It  is  for  the  purpose  of  overcoming  these 
folds  as  far  as  possible  that  we  distend  the  bladder  with  fluid 
previous  to  the  introduction  of  the  instrument.  The  cystoscope, 
handled  as  a  lever,  with  the  bottom  of  the  end  of  the  shaft  always 
firmly  pressed  on  the  floor  of  the  bladder,  prevents  the  folds  of  the 
prostate,  or  of  the  trigonal  portion  of  the  bladder,  from  rising  too 
much  and  obscuring  the  view,  and  thus  keeps  the  orifice  of  the 
ureter  from  getting  behind  the  fold  of  the  trigone  to  such  an  ex- 
tent as  to  make  introduction  of  the  ureteral  catheter  impossible. 

This  latter  annoyance  will  often  vex  the  observer  when  the 
fluid  placed  in  the  bladder  has  escaped  during  the  attempt  at  cathe- 
terization of  the  ureters. 

In  order  to  properly  use  the  instrument,  the  bladder,  emptied 
of  urine,  should  be  filled  with  from  8  to  12  ounces  of  a  colorless 
aseptic  fluid.  It  may  be  well  to  remark  here  that  if  urethritis  or 
cystitis  has  been  present,  the  bladder  must  be  washed  several 
times  in  succession  so  as  to  be  perfectly  free  from  shreds  or  mucus, 
which  would  tend  to  make  the  urine  cloudy.  With  a  clear  and 
clean  field,  and  about  as  much  fluid  in  the  bladder  as  it  will  com- 
fortably hold,  the  instrument  should  be  passed  through  the  ure- 
thra in  the  classic  manner,  depressing  the  handle  of  the  cysto- 
scope well  between  the  patient's  legs  before  attempting  to  pass  it 
into  the  bladder.     This  having  been  accomplished,  the  mandarin 


74        ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

removed,  the  light  inserted,  and  the  connection  between  the  cysto- 
scope  and  the  battery  having  been  made,  the  current  should  be 
turned  on  until  the  light  of  the  lamp  is  almost  white.  The  cyst- 
oscope  should  then  be  pushed  backward  until  it  meets  the  pos- 
terior wall  of  the  bladder. 

In  looking  through  the  eye-piece,  the  back  wall  of  the  bladder 
will  be  found  to  be  a  comparatively  clear,  light-colored  field. 
The  beak  of  the  instrument  should  now  be  brought  forward  a 
little — not  pulled  straight  outward,  but  brought  forward— by 
raising  the  outer  end  of  the  instrument  slightly  toward  the  um- 
bilicus and  keeping  the  beak  in  the  bladder  well  pressed  down 
toward  the  bladder  floor,  the  instrument  being  held  in  the  median 
line,  with  the  roof  of  the  beak  always  pointing  toward  the  roof  of 
the  bladder.  A  dark  ridge  will  soon  make  its  appearance  at  the 
bottom  of  the  field  as  observed  through  the  eye-piece.  This  is 
the  apex  of  the  prostate,  and  is  also  the  apex  of  the  triangle,  which, 
for  the  inexpert,  must  be  located  before  searching  for  the  mouths 
of  the  ureters.  Now,  if  the  instrument  is  carried  a  little  to  one  side, 
the  dark-colored  ridge  of  the  trigone  will  be  seen  running  off  in  a 
diagonal  direction  from  this  apex ;  and  if  the  instrument  is  carried 
a  little  to  the  other  side,  but  not  rotated,  a  similar  ridge  will  be 
seen.  This  ridge  is  a  dark  fold, — almost  as  dark  as  the  apex  of 
the  prostate, — and  a  distinct  line  of  demarcation  exists  between 
it  and  the  lighter  colored  bladder-wall.  About  half  way  up  this 
ridge,  following  along  the  edge  of  it  (along  the  line  of  demarcation 
between  it  and  the  bladder- wall) ,  and  about  an  inch  from  the 
apex  of  the  prostate,  the  mouth  of  the  ureter  is  ordinarily  to  be 
found,  but  is  at  times  located  only  after  taxing  the  patience  and 
watchfulness  of  the  observer.  It  appears  as  a  small  elevation  or 
slight  blur.  Occasionally  the  urine  may  be  seen  coming  from  it 
like  a  little  puff  of  smoke.  Having  found  the  mouth  of  the  ureter, 
or,  if  this  has  not  been  possible,  having  found  the  place  where  ordi- 
narily it  should  be,  the  next  point  is  to  introduce  the  catheter. 
This  is  accomplished  with  more  ease  if  the  bladder  is  well  distended 
with  fluid.  One  difficulty  may  be  met  here — namely,  the  de- 
termining of  the  proper  focus:  the  focus  must  be  adjusted  to 
each  pair  of  eyes,  and,  as  with  an  opera  glass,  the  right  focus  for 
one  person,  is  not  necessarily  that  for  another.     The  proper  focus 


INSTRUMENTAL   EXAMINATION  OF  THE   KIDNEY  75 

must  be  obtained  either  by  pushing  the  instrument  a  little  more 
firmly  against  the  bladder-wall  or  by  drawing  it  outward,  taking 
care  to  avoid  lateral  or  rotary  movement.  This  focusing  is,  as  has 
been  said,  one  of  the  most  difficult  parts  of  the  operation,  and 
requires  practice  and  experience. 

The  catheter,  on  being  pushed  gently  forward,  no  force  having 
been  used,  and  the  proper  focus  having  been  found,  except  as  in 
cases  of  malposition  or  of  ureteral  stricture,  it  enters  the  ureter. 
If  in  doubt,  leave  the  catheter  in  position,  withdraw  the  instru- 
ment a  little,  and,  looking  through  the  eye-piece,  observe  whether 
it  has  entered  the  ureter  or  is  doubled  up  in  the  bladder. 

The  catheter  having  been  introduced  into  the  ureter  on  one 
side,  the  instrument  should  then  be  returned  to  the  apex  of  the 
prostate  and  run  along  the  border  of  the  trigone  on  the  other  side 
until  the  orifice  of  the  other  ureter  is  found  and  the  catheter  in- 
troduced there.  Then  the  shaft  of  the  instrument  may  be  taken 
out,  leaving  the  two  catheters  in  position,  or,  instead  of  introduc- 
ing the  catheter  into  the  second  ureter,  it  is  preferable,  in  many 
cases,  the  fluid  in  the  bladder  having  been  entirely  withdrawn, 
to  allow  the  end  of  the  catheter  to  remain  in  the  bladder,  while 
the  other  catheter  would  remain  in  the  ureter.  The  urine  from 
the  other  kidney  would  naturally  flow  through  the  catheter  re- 
maining in  the  bladder,  provided  no  leakage  from  the  kidney 
occurs  around  the  first  catheter  placed  in  that  organ.  The  two 
catheters  having  been  left  in  this  position,  the  patient's  legs  may 
be  released  from  the  rests,  and  he  may  be  allowed  to  rest  quietly 
and  comfortably  on  his  back  while  the  urine  passes  through  the 
catheters  for  half  an  hour  or  more. 

The  position  of  the  legs  of  the  patient  while  the  catheter  cysto- 
scope  is  being  used  is  an  important  feature.  A  pair  of  uprights 
should  be  placed  on  the  table,  from  which  are  suspended  two  can- 
vas stirrups  for  the  patient's  feet;  the  patient's  body  should  be 
brought  to  the  edge  of  the  table,  and,  when  adjusted,  the  lowest 
part  of  the  canvas  stirrups  should  be  about  sixteen  inches  higher 
than  the  edge  of  the  table.  Still  better  than  the  stirrups  are  the 
rests  shown  in  our  illustrations  (Figs.  31  and  32). 

How  to  Catheterize  the  Ureter  with  the  Reverse  Cystoscope. — The 
Bierhoff  Modification  of  the  Nitze-Alharran  Cystoscope. — In  using 


76        ENDOSCOPY. — CYSTOSCOPY. — URETER  CATHETERIZATION 

this  instrument  the  position  of  the  patient  and  the  intensity  of 
the  Hght  should  be  the  same  as  with  the  instrument  previously 
described,  but  the  operator  does  not  see  straight  ahead  with  it, 
however,  and  with  this  form  of  cystoscope  rotation  is  necessary. 
The  field  of  vision  is  about  that  shown  by  us  in  the  illustration  of 
the  field  of  vision  of  the  Nitze  exploring  bladder  cystoscope  (p.  56). 
The  cystoscope  having  been  introduced  with  its  beak  pointing  up- 
ward, the  roof  of  the  bladder  will  naturally  first  be  seen.  The 
instrument  should  now  be  rotated  through  an  angle  of  aibout 
75°  and  pushed  slightly  to  one  side.  The  field  of  vision  now 
includes  the  point  at  which  the  ureters  should  be  found.  It  may 
be  advisable  to  turn  the  instrument  completely  about,  so  that  the 
apex  of  the  beak  points  directly  downward  to  find  the  prostate 
and  trigone  ridge,  and  through  the  aid  furnished  by  observation 
of  their  position,  locate  the  ureter.  The  prostate  and  the  trigone 
ridge  in  the  use  of  this  cystoscope  will  appear  at  the  upper  part 
of  the  cystoscopic  field  instead  of  at  the  lower  part,  as  in  the 
cystoscope  of  the  straight  type.  The  mouths  of  the  ureters  being 
located,  the  catheter  should  be  pushed  forward  until  its  end 
strikes  the  mouth  of  the  ureter.  This  extension  of  the  catheter 
takes  place  under  the  eye  of  the  observer.  The  instrument 
should  then  be  very  slightly  withdrawn,  and  an  attempt  made, 
through  bringing  into  use  the  metal  finger  on  the  instrument,  to 
introduce  the  catheter  into  the  ureter.  One  catheter  having  been 
introduced,  search  should  be  made  for  the  mouth  of  the  other 
ureter  and  the  procedure  repeated.  Two  manipulations  should 
now  be  performed  before  withdrawing  the  cystosciDpe  and  leaving 
the  catheters  in  position.  The  first  consists  in  replacing  the 
metal  finger  by  means  of  the  screw  attachment,  so  it  will  not 
protrude  in  the  withdrawal,  as  otherwise  the  urethra  would  be 
torn.  The  second  step  consists  in  loosening  the  screw  at  the 
outer  end  of  the  cystoscope,  so  that  the  beak  can  be  rotated 
until  it  points  upward  without  rotating  the  sheath  that  holds 
the  catheters.  Through  this  procedure  the  instrument  may  be 
withdrawn  without  pulling  the  catheters  out  of  the  ureters,  as 
they  will  still  be  in  the  dependent  portion  of  the  instrument 
until  it  is  removed.  Constant  practice  and  good  eye-sight  are 
important   factors  "  in    making  one  expert    in    catheterizing  the 


INSTRUMENTAIv   EXAMINATION    OP   THE    KIDNEY  77 

ureters.  Many  of  the  difficulties  previously  encountered,  such  as 
large  shafts  to  the  instruments,  inferior  lenses,  inadequate  light- 
ing facilities,  and  defective  lamps  that  would  easily  burn  out,  have 
now  been  overcome  by  enterprising  manufacturers.  Very  recently 
the  Wappler  Manufacturing  Co.  have,  at  our  suggestion,  made 
a  single  indirect  ureter  catheter  cystoscope,  which,  while  it  can- 
not be  recommended  in  preference  to  those  already  mentioned, 
is  comparatively  inexpensive  and  seems  a  useful  and  practical 
instrument. 

Operative  Cystoscopes. — Concerning  the  so-called  operative 
cystoscope,  through  which  a  snare  is  placed  or  a  cautery  for  the 
purpose  of  the  removal  or  treatment  of  bladder  tumors  when 
deemed  advisable,  while  no  one  has  as  yet  succeeded  in  rivaling 
the  wonderful  results  obtained  by  the  late  Dr.  Nitze  through 
the  use  of  his  operating  cystoscope,  and  while  criticism  has 
been  made  in  early  editions  of  this  work  for  recommending  at 
all  the  use  of  operating  cystoscopes,  it  is  our  firm  belief  that  their 
field  of  usefulness  is  extending,  and  that,  as  familiarity  with 
the  use  of  the  cystoscope  increases,  more  and  more  work  will 
be  done  through  their  instrumentality.  It  is  not  expected  that 
they  will  ever  supersede  more  pronounced  operative  procedures 
through    the   bladder-wall:   still   instrumentation    through    them 


Fig.  39. — The  Schapira  universal  cystoscope,  showing  lithotrite  attachment. 

on  very  small  bladder  tumors  seems  undoubtedly  in  certain  cases 
to  be  attended  with  good  results. 

Through  the  use  of  the  operative  cystoscope  the  recurring 
growths  previously  operated  on  through  bladder  incisions  may 
be  treated,  and  two  different  types  of  high-frequency  currents 
applied  to  bladder  growths,  cauterizing  the  same.  With  the 
Oudin  current,  the  one  most  frequently  used,  the  application  is 
made  through  a  wire  attached  to  the  instrument  running  through 


78        ENDOSCOPY.— CYSTOSCOPY.— URETER   CATHETERIZATION 

the  cystoscope  and  the  appUcation  is  made  directly  to  the  tumor. 
Fulguration  is  the  name  appHed  to  this  process.     In  applying  the 


Pig,  40. — A,  end  of  wire  connecting  with  wire  in  Fig.  35. 


FiK  41.— Wappler's  portable  diathermic  high-frequency  apparatus,  wire  from  which  connects 
with  wire  running  through  cystoscope.  Another  wire  connects  with  indiflferent  tin  electrode  Lo 
be  placed  on  buttocks. 

spark  to  the  tumor  when  the  current  is  strong  enough  to  act  on 
the  tissue  a  few  air  bubbles  will  be  seen  coming  off  from  the  spot 
where  the  current  is  applied,  the  bladder  having  previously  been 


INSTRUMENTAL   EXAMINATION    OF    THE    KIDNEY  79 

filled  with  fluid.  The  part  to  which  the  wire  has  been  applied  is 
bleached,  A  little  bit  of  tissue,  white  in  color,  becomes  detached 
from  the  tumor  and  can  frequently  be  seen  floating  in  the  fluid. 
When  this  appears  it  denotes  that  considerable  necrosis  has  taken 
place.  As  a  general  rule  the  applications  can  be  made  about  every 
three  days  of  from  fifteen  to  twenty  seconds  up  to  two  minutes  or 
more  until  the  entire  tumor  has  been  thoroughly  fulgurated.  At 
first  treatments  should  be  made  only  for  a  short  time,  but  each 
case  studied  by  itself,  the  danger,  of  course,  being  that  of  burn- 
ing through  the  bladder  wall. 

The  d'Arsonval  current  has  a  somewhat  similar  action  to  the 
Oudin  current.  This  is  given  by  the  application  of  an  electrode  to 
the  body,  generally  over  the  abdomen,  and  another  applied  directly 
to  the  tumor. 

Methods    of    Separating    the    Urine   from    Each    Kidney 

WITHOUT  CaTHETERIZING  THE  URETERS 

A  year  or  two  ago  the  consideration  of  the  different  methods 
of  urine  separation  by  the  aid  of  various  separators  would  have 
consumed  more  space  than  is  at  present  demanded.  So  long  as 
the  difficulties  of  catheterization  of  the  ureters  seemed  almost 
insurmountable,  any  new  methods  of  separating  the  urine  were 
received  with  decided  enthusiasm;  since,  however,  it  has  been 
learned  that,  once  one  is  familiar  with  the  process  of  catheteriz- 
ing  the  ureters,  the  simple  operation  may  be  repeated  as  often  as 
occasion  demands,  the  various  urinary  segregators  and  separators 
have  somewhat  fallen  into  disuse  and  come  to  be  considered  un- 
important. As  time  goes  on  it  may  be  demonstrated  that  we 
are  in  error  in  making  this  observation.  The  fact  remains, 
nevertheless,  that  at  present  an  ideal  segregator  or  separator  does 
not  exist;  and  although  some  of  these  instruments  that  are  now 
in  use  are  of  value,  and  attest  to  the  very  commendable  mechanical 
ingenuity  of  their  inventors,  still,  the  writers'  experience  and 
that  of  other  investigators  places  them  in  favor  of  catheteriza- 
tion. It  is  the  writer's  belief  that,  in  order  properly  to  understand 
the  use  of  segregators  and  separators,  as  much  perseverance 
and  skill  are  necessary  as  are  required  for  catheterizing  the 
ureters;   and,  from  clinical  experience,  it  would  seem  to  be  about 


8o        ENDOSCOPY.  ^ — CYSTOSCOPY. — URETER    CATHETERIZATION 

as  easy  to  obtain  consent  for  performing  catheterization  as  for 
using  the  segregators.  In  exceptional  cases,  where  the  process  of 
catheterizing  the  ureters  has  been  so  painful  to  the  patient  that 
he  objects  to  further  attempts  at  it,  the  segregators  may  be  used. 
It  is  by  no  means  intended  to  convey  the  idea  that  these  segrega- 
tors are  valueless,  for  this  is  not  the  case.  The  Harris  segregator 
is  an  instrument  for  which  the  profession  should  feel  grateful. 
By  its  use,  years  ago,  when  it  was  first  placed  upon  the  market, 
the  writers  found  unilateral  albuminuria  in  cases  of  chronic  neph- 
ritis, also  casts  in  the  secretion  of  only  one  kidney.  At  that  time 
its  use  demonstrated  how  httle  was  then  known  as  to  the  nature  of 
B right's  disease. 

The  Cathelin  instrument  has  been  used  by  the  house  staff  of 
the  City  Hospital  of  New  York  with  apparently  satisfactory  re- 
sults in  some  cases.  In  a  recent  work  entitled  "  Considerations  sur 
la  Methode  de  la  Separation  Intra- vesicale  des  Urines"  ("Extrait 
des  Annales  des  Maladies  des  Organes  Genito-urinaires,"  15.  Jan- 
vier, 1906)  Dr.  Georges  Luys  has  considered  the  different  segrega- 
tors very  exhaustively.  In  general,  segregators  are  of  two  kinds: 
first,  those  in  which  an  instrument  introduced  into  the  rectum 
makes  a  bridge  in  the  bladder;  this  is  combined  with  a  sound- 
shaped  instrument  that  separates  into  two  finger-like  projections 
and  presses  the  bladder  into  two  pockets ;  the  Harris  instrument  is 
of  such  a  type ;  second,  those  on  the  order  of  the  Luys  or  Cath- 
elin instruments,  which  are  sound  shaped,  but  in  which  there  is 
a  rubber  membrane  that  divides  the  bladder  into  two  chambers. 

TESTS  SHOWING  THE  DEGREE  OF  KIDNEY  PERMEABILITY 

Tests  for  the  estimation  of  the  kidney  function  have  been  shown 
in  the  past  few  years  to  be  of  such  importance  that  medical  litera- 
ture is  becoming  crowded  with  considerations  of  this  subject. 
New  tests  are  continually  being  brought  forward  and  some  of  the 
earlier  ones  are  necessarily  pushed  into  the  background.  In 
previous  editions  of  this  work  this  subject  has  been  considered  with 
some  detail,  and  particular  attention  was  paid  to  giving  the  results 
as  we  have  found  them  in  our  work  rather  than  to  theoretic  con- 
siderations of  matters  concerning  these  tests  with  which  we  have 
had  no  personal  experience.     Originally,  these  tests  were  to  a  great 


TESTS  SHOWING  THE  DEGREE   OF   KIDNEY  PERMEABILITY      8 1 

extent  used  with  ureteral  catheterization  in  an  effort  to  show  the 
condition  of  each  kidney  separately  in  relation  to  operative  pro- 
cedures. Lately,  we  have  gone  somewhat  farther  in  the  matter 
and  have  endeavored  to  devise  a  rather  rough-and-ready  test  that 
could  be  used  by  the  general  practitioner  as  well  as  by  the  surgeon 
or  laboratory  worker,  and  which  could  be  made,  if  necessity  re- 
quired it,  in  the  office  or  at  the  bedside,  believing  that  there  is  more 
demand  for  such  a  test  than  for  those  the  carrying  out  of  which  is 
a  very  elaborate  procedmre. 

We  have  purposely  eliminated  from  this  edition  consideration 
of  some  procedures  which  have  previously  been  discussed,  either 
on  account  of  their  lack  of  practicability,  or  from  the  fact  that  the 
carrying  out  of  them  required  such  attention  to  detail  as  to  rele- 
gate them  to  laboratory  workers  only.  While  many  of  these  more 
elaborate  tests  have  great  value,  a  better  study  of  them  can  be 
made  from  articles  devoted  to  them  exclusively,  rather  than  in  a 
work  devoted  to  purely  clinical  subjects. 

Among  such  tests  considered  by  us  in  previous  editions,  but 
which  we  no  longer  use,  are  the  methylene-blue  test;  the  polyuria 
test  (Albarran),  and  cryoscopy. 

Since  the  last  edition  of  this  work  we  have  carried  on  quite  ex- 
tensive investigations  of  the  subject,  but  have  used  mostly  three 
tests,  each  one  of  which  we  have  found  to  possess  considerable  diag- 
nostic value.  We  have  used  these  tests  in  large  numbers  of  individ- 
ual cases,  and  also  in  a  series  of  cases  in  which  each  of  the  three  tests 
was  used  on  the  same  individual,  in  order  that  the  findings  given 
might  be  compared  and  the  relative  accuracy  of  diagnosis  and  prog- 
nosis confirmed  by  further  medical  study  by  surgical  operation  or 
at  the  autopsy. 

These  three  tests  have  been  the  estimation  of  the  nitrogen  in 
the  urine  compared  with  nitrogen  retained  in  the  blood  according 
to  the  method  of  Otto  Folin  or  some  of  its  modifications  ("Journal 
of  Biological  Chemistry,"  II,  1912,  and  Hawkes,  "Practical  Phys- 
iologic Chemistry");  the  phenolsulphonephthalein  and  the  phlor- 
idzin  tests. 

The  nitrogen  test  has  the  disadvantage  that  it  requires  the  ser- 
vices of  an  expert  chemist  familiar  with  detailed  and  elaborate 
laboratory  methods  usually  to  be  found  outside  of  a  biologic 
6 


82        ENDOSCOPY. — CYSTOSCOPY. — URETER  CATHETERIZATION 

laboratory;  but  its  results  are  so  accurate  that,  on  the  whole, 
we  find  it  the  most  useful  of  the  three,  and  we  believe  it  of 
great  advantage  both  in  the  diagnosis  and  prognosis  of  renal 
deficiencies. 

It  is  most  important  to  note,  however,  that  for  the  accurate  use 
of  this  method  a  constant,  determined,  and  low  nitrogen  diet  must 
be  first  given. 

As  yet  the  methods  differ  considerably.  Some,  as  Chase,  Halsey, 
and  their  students,  do  a  nitrogen  partition  on  the  filterable  blood 
nitrogen,  and  as  a  result  apparently  feel  that  the  gravity  of  prog- 
nosis hangs  chiefly  on  the  creatinin  present;  while  others,  as 
Larken,  at  the  City  Hospital,  place  greater  reliance  on  the  total 
filterable  nitrogen  present.  This  last  method,  which  we  have 
chiefly  employed,  is  by  far  the  more  simple,  nor  do  we  find  that  it 
suffers  thereby  in  accuracy. 

The  idea  has  been  rather  recently  advanced  that  the  abnormal 
retention  of  uric  acid  in  the  blood  is  one  of  the  early  precursors  of 
renal  incompetence.  Certainly  a  huge  blood  uric  acid  content  is 
present  in  nearly  all  cases  of  kidney  deficiency,  but  whether  it  is 
an  accompaniment  or  a  true  index  of  this  state  is  still  in  question. 
Certainly  in  such  instances  the  differentiation  from  gout,  with  or 
without  renal  defects,  is  most  difficult  chemically.  When  a  broad 
comprehensive  clinical  view  of  a  case  is  taken,  however,  as  we  have 
observed  it,  little  likelihood  of  error  is  possible. 

At  first  heralded  as  an  almost  infallable  prognostic  sign,  retention 
of  filterable  blood  nitrogen  has  now  been  shown  to  be  influenced  by 
many  factors,  as  by  food,  excretion  by  other  avenues,  or  by  medic- 
inal agents.  When,  however,  the  blood  nitrogen  remains  con- 
stantly high  or  does  not  decrease  under  treatment,  it  must  be  cer- 
tainly considered  as  among  the  most  certain  and  absolute  of  bad 
prognostic  signs. 

Phenolsulphonephthalein  Test. — This  is  a  color  test  for  deter- 
mining kidney  permeability  which  has  recently  been  introduced 
to  the  profession  for  that  purpose  by  L.  G.  Rowntree  and  J.  T. 
Gerachty,^  its  pharmacology  having  been  previously  studied  by 

^ "  An  Experimental  and  Clinical  Study  of  the  Functional  Activity  of  the 
Kidneys  by  Means  of  Phenolsulphonephthalein,"  Journal  of  Pharmacology 
and  Experimental  Therapeutics,  vol.  i.  No.  6,  July,  1910. 


TESTS   SHOWING   THE!   DEGREE)    OF   KIDNEY   PERMEABII^ITY      83 

Abel  and  Rowntree.^  Its  method  of  administration  is  as  fol- 
lows : 

Twenty  minutes  to  half  an  hour  before  commencing  the  test  the 
patient  is  given  300  to  400  c.c.  of  water  in  order  to  insure  a  free 
urinary  secretion  and  prevent  delay  in  time  of  appearance.  Cathe- 
ter introduced  and  the  bladder  emptied.  Catheter  allowed 
to  remain;  i  c.c.  of  phenolsulphonephthalein  solution  containing 
6  mg.  to  the  cubic  centimeter  is  administered  subcutaneously  or 
intramuscularly.  The  solution  is  prepared  as  follows:  0.6  gram 
of  phenolsuphonephthalein  and  0.84  c.c.  of  ^;  NaOH  solution  are 
added  to  0.75  per  cent.  NaCl.  solution.  This  gives  the  mono- 
sodium  or  acid  salt,  which  is  red  in  color  and  which  is  slightly  irri- 
tant locally  when  injected.  It  is  necessary,  therefore,  to  add 
two  or  three  drops  more  of  the  ^  hydroxid,  a  quantity  sufficient  to 
change  the  color  to  a  beautiful  Bordeaux  red.  This  preparation 
is  non-irritant.  The  urine  is  allowed  to  drain  into  a  test-tube  in 
which  has  been  placed  a  drop  of  25  per  cent.  NaOH  solution. 
Time  of  appearance  of  first  pinkish  tinge  is  noted.  Then  urine  is 
collected  for  one  hour,  care  being  taken  to  see  that  the  bladder  is 
thoroughly  emptied  and  the  time  taken.  Then  the  urine  is  col- 
lected for  the  second  hour  and  the  time  taken.  Bach  sample  of 
urine  is  measured  and  specific  gravity  taken.  Enough  of  the  25 
per  cent.  NaOH  solution  is  added  to  make  the  urine  decidedly 
alkaline  in  order  to  elicit  the  maximum  color.  In  acid  urine  the 
color  is  yellow  or  orange,  which  becomes  purple-red  when  the  solu- 
tion is  made  alkaline.  The  solution  is  then  placed  in  a  liter  meas- 
ure-flask and  distilled  water  added  to  make  accurately  i  liter. 
The  solution  is  then  thoroughly  mixed  and  a  small  filtered  portion 
is  taken  to  compare  with  the  standard  which  is  used  for  all  these 
estimations.  The  use  of  a  colorimeter  is  required,  the  Duboscq 
being  the  one  recommended  for  the  purpose. 

Quoting  from  the  work  referred  to,  the  remainder  of  the  process 
is  as  follows: 

"The  standard  solution  used  for  comparison  consists  of  3  mg. 
of  phenolsulphonephthalein  (or  |  c.c.  of  the  solution  used  for 
injection)  diluted  up  to  i  liter  and  made  alkaline  by  the  addition 
of  only  one  or  two  drops  of  25  per  cent.  NaOH  solution.    This  is  a 

^Journal  of  Pharmacology  and  Experimental  Therapeutics,  vol.  i,  p.  231. 


84        ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

beautiful  purplish-red  solution,  retaining  its  intensity  of  color 
for  weeks  or  for  an  indefinite  period.  The  one  solution,  therefore, 
serves  for  an  immense  number  of  tests. 

"  One  cup  of  the  colorimeter  (right)  is  half -filled  with  this 
standard  solution  used  for  comparison,  which  has  just  been  de- 
scribed, and  the  plunger  lowered  so  that  the  indicator  reads  at  lo. 
A  varying  quantity  (depending  on  the  intensity  of  the  color) 
of  the  diluted  urine  is  placed  on  the  other  cup,  and  the  plunger 
manipulated  until  the  two  halves  of  the  field  are  of  an  identical 
intensity  of  color.  The  indicator  of  the  left  plunger  is  now 
read,  the  fraction,  as  indicated  by  the  Vernier  scale,  being  taken 
into  account.  The  estimation  of  the  quantity  present  is  then  a 
question  of  simple  arithmetic. 

"For  instance,  the  left  side  reads  at  20 — the  standard  being 

placed  at  10.     In  other  words,  it  takes  a  column  of  fluid  twice  as 

long  to  give  the  same  intensity  of  color  as  that  of  the  standard, 

which,  of  course,  shows  that  the  solution  contains  only  half  as 

much  as  dye.     To  obtain  the  percentage  of  dye  excreted  in  the 

urine  compared  with  the  amount  in  the  standard  solution  used  for 

comparison  it  is  necessary  to  multiply  the  reading  of  the  standard 

by  100  and  divide  by  the  reading  indicated  for  the  solution  con- 

.    .         ,  .  „  10  X  100 

taming  the  urme.     To  return  to  our  example :  we  have 

20 

=  50  per  cent.,  as  much  drug  in  the  urine  as  in  the  standard  solu- 
tion used  for  comparison. 

"  The  3  mg.  to  the  liter  standard  for  comparison  has  been 
chosen  arbitrarily  because  of  the  beautiful  pink  color  which  is 
obtained  when  the  indicator  stands  at  10.  The  amount  of  drug 
used  for  injection  is  6  mg.  chosen  for  reasons  stated  above.  We 
have  compared  the  amount  of  drug  in  the  diluted  urine  with  that 
of  the  standard  for  comparison,  but,  if  we  wish  to  estimate  the 
amount  of  drug  excreted  as  compared  with  the  amount  of  drug 
administered,  we  must  compare  the  amount  excreted  with  6  mg. 
rather  than  3  mg.,  which  is  present  in  the  solution  for  comparison. 
In  the  example  given  above  we  would  have  50  per  cent,  of  the 
3  mg.  or  25  per  cent,  of  the  6  mg.,  which  was  the  amount  in- 
jected; so  that  the  excretion  is  25  per  cent,  of  the  amount  ad^ 
ministered." 


TESTS    SHOWING   THE   DEGREE    OF    KIDNEY   PERMEABIIvlTY      85 

Quite  satisfactory  results  may  also  be  obtained  by  the  simple  and 
inexpensive  Dunning  colorimeter. 

A  slight  source  of  error  may  be  present  if  the  patient  excretes 
more  than  200  c.c.  of  urine  an  hour.  Methods  for  overcoming 
this  error  are  described  in  the  article  referred  to. 

Rowntree  and  Gerachty  in  their  study  of  normal  cases  found  the 
time  of  appearance  varied  from  five  to  eleven  minutes  and  that 
40  to  60  per  cent,  of  the  drug  was  excreted  in  the  first  hour  and 
from  20  to  25  per  cent,  in  the  second  hour,  that  from  60  to  85  per 
cent,  was  excreted  in  two  hours,  and  that  the  excretion  of  the  drug 
does  not  run  parallel  to  the  excretion  of  water. 

This  test  maj^  be  very  conveniently  employed  either  in  the 
office  or  home  and  does  not  require  hospital  or  elaborate  laboratory 
study. 

Phloridzin  Test. — In  previous  editions  of  this  work  we  have 
stated  that  we  consider  this  latter  test  the  most  practical.  Farther 
experience  with  its  use  has  demonstrated  the  general  correctness  of 
the  views  then  held,  though  in  intern  work  the  first  two  methods 
are  more  useful. 

In  the  comparative  series  of  cases  mentioned  above  it  was 
found  by  us  to  be  but  slightly  less  accurate  than  the  nitrogen 
determination  studies,  and  slightly  more  so  than  the  phenolsulpho- 
nephthalein  test.  The  resemblance  of  the  results  obtained  from 
each  of  the  three  tests  is  very  close,  but  the  phloridzin  test  is  the 
one  recommended  by  us  for  routine  surgical  work.  The  findings 
from  its  use,  however,  should  be  checked  up  by  one  or  both  of  the 
other  tests  mentioned,  when  in  doubt.  All  of  these  tests  are  of 
use  in  connection  with  ureteral  catheterization,  but  in  our  endeavor 
to  find  a  simple  test,  without  that  procedure,  the  phloridzin  more 
than  any  other  meets  surgical  requirements. 

We  recommend  a  solution  of  phloridzin  i  :  400,  of  which  30 
minims  are  to  be  injected  ^ubcutaneously  in  the  gluteal  region. 
This  solution  is  twice  as  much  in  quantity  and  contains  one-half 
the  amount  of  phloridzin  previously  recommended  by  us,  but  has 
the  advantage  of  being  a  stable  solution. 

Thirty  minutes  after  the  injection  in  a  normal  individual  a  trace 
of  sugar  should  be  found  in  the  urine  by  one  of  the  ordinary  fairly 
accurate  tests,  such  as  Benedict's  or  Whitney's. 


86        ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

The  presence  of  sugar  in  thirty  minutes  is  proof  positive  that  the 
kidneys  are  in  a  fairly  healthful  condition,  or  at  least  doing  their 
work,  but  the  converse  to  the  above  proposition  is  not  correct. 

The  absence  of  sugar  in  thirty  minutes  can  be  taken  to  demon- 
strate that  there  is  some  interference  with  proper  tissue  metamor- 
phosis, most  generally  due  to  some  impairment  of  the  kidney  func- 
tion, but  it  may  be  due  to  a  variety  of  other  causes,  such  as  arterio- 
sclerosis, malignant  growths,  or  various  disturbances  of  the  ner- 
vous system.  Therefore  when  sugar  is  found  to  be  delayed  or 
absent,  it  is  an  indication  that  a  still  more  exhaustive  examination 
of  the  patient  should  be  made  and  further  investigations  of  the 
urinary  secretion  made.  Not  infrequently  sugar  is  absent  from 
forty-five  minutes  to  one  or  two  hours,  or  may  not  appear  at  all. 
As  a  general  statement  it  may  be  said  that  the  longer  the  delay 
in  the  appearance  of  sugar,  the  more  extensive  probable  renal 
changes  are.  In  cases  of  enlarged  prostate  with  residual  urine 
the  bladder  should  be  emptied  before  the  phloridzin  is  injected 
and  the  catheter  allowed  to  remain  in  the  bladder  during  the  time 
that  the  test  is  being  carried  on.  This  procedure  can,  of  course, 
be  used  in  other  cases  if  deemed  necessary. 

Though  we  all  recognize  the  great  and  increasing  value  of  these 
tests,  they  in  no  way  invalidate  or  supercede  the  older  methods,  as 
the  careful  examination  of  the  urine  and  especially  the  general 
clinical  consideration  of  any  case.  The  new  methods  assist  us 
very  greatly  especially  as  to  accuracy  in  prognosis  and  diagnosis, 
but  they  cannot  replace  the  older  and  fully  established  methods  of 
the  study  of  renal  diseases. 

Test  Showing  Permeability  of  the  Kidney  Associated  -with 
Ureter  Catheterization 

More  and  more  attention  is  being  paid  to  this  subject  on  ac- 
count of  the  great  importance  in  kidney  operations  of  finding  out 
the  functional  value  of  the  kidney  which  is  not  to  be  operated  on. 
This  is  of  particular  importance  when  both  kidneys  are  diseased, 
but  in  different  degree. 

In  addition  to  whatever  information  may  be  obtained  by  pal- 
pation, by  massage  over  the  surface  of  each  kidney  separately,  by 
the  appearance  of  the  mouths  of  the  ureters  through  the  cysto- 


PERMEABILITY  OF   KIDNEY  ASSOCIATED   WITH  CATHETERIZATION   87 

scope,  by  the  ease  with  which  ureter  catheterization  is  performed, 
and  by  any  other  general  measures  which  may  suggest  themselves, 
we  recommend  the  following  tests  for  this  purpose:  The  indigo- 
carmin  test,  the  phloridzin  test  (details  mentioned  above),  and  a 
very  simple  but  useful  test  reported  by  F.  Voelcker,  of  Heidelberg 
(Report  of  the  International  Congress  in  the  Journal  d'Urologie, 
August,  19 14,  vol.  vi,  No.  2),  the  water  test. 

These  tests  are  valuable,  particularly  in  cases  of  tuberculosis, 
where  both  kidneys  are  affected.  In  commencing  tuberculosis 
one  frequently  encounters  the  symptoms  of  hypo-azoturia,  in  which 
there  is  a  polyuria  with  clear  urine,  but  in  which  the  kidney  is  not 
able  to  give  a  concentrated  lurine. 

Indigo-carmin  Test. — Voelcker  and  Joseph,  who  devised  this 
test,  found  that  indigo-carmin  injected  hypodermically  is  excreted 
by  the  kidneys  as  a  blue  coloring-matter.  They  dissolved  0.4  gm. 
of  carmin  in  10  cm.  of  physiologic  salt  solution  and  injected  4  gm. 
into  the  gluteal  muscle.  The  coloring-matter  normally  makes  its 
appearance  in  the  urine  about  ten  minutes  after  the  injection.  In 
order  that  the  urine  may  be  concentrated  they  limit  the  fluid  in- 
take before  the  test.  Later  the  injection  of  20  cm.  was  recom- 
mended, in  which  case  the  reaction  occurred  in  from  three  to  five 
minutes  and  the  height  of  excretion  was  attained  in  from  one-half  to 
three-quarters  of  an  hour.  Delayed  reaction  indicates  renal  in- 
sufficiency. Kapsammer  states  that  the  power  of  the  kidney  to 
excrete  may  be  also  advantageously  tested  by  reducing  or  increas- 
ing the  concentration  of  the  solution. 

This  test  in  our  experience  is  of  considerable  value  associated 
with  catheterization  of  the  ureters  so  as  to  indicate  the  condition  of 
each  kidney  separately.  The  difficulty  that  we  have  found  with  it 
for  general  work  is  that  it  is  not  elastic  enough,  the  variations  in 
color  being  so  slight  that  the  data  given  through  its  use  is  not  ex- 
haustive enough  to  render  a  very  valuable  aid  except  to  the  extent 
above  mentioned. 

The  Water  Test. — The  proof  by  means  of  thirst  is  then  instituted, 
that  is,  an  attempt  is  made  by  withholding  fluid  to  see  if  the  kidney 
has  elasticity  enough  to  secrete  fluid  of  a  higher  specific  gravity. 
If  the  kidney  is  found  to  perform  this  function  satisfactorily,  in 
order  to  test  it  to  see  whether  such  results  are  simply  causal  or  not 


88        ENDOSCOPY. — CYSTOSCOPY. — URETER   CATHETERIZATION 

a  large  amount  of  fluid  is  then  ingested  to  see  if  the  same  kidney  will 
again  produce  urine  of  a  low  specific  gravity.  On  the  other  hand, 
if  a  kidney  is  found  in  which  the  specific  gravity  is  high,  a  large 
amount  of  fluid  is  ingested  in  order  to  see  if  the  specific  gravity  of 
the  urine  becomes  lower,  and  in  order  to  test  this  too  for  what  may 
be  termed  its  elasticity.  As  a  check  a  smaU  amount  of  fluid  is 
then  only  permitted  to  be  ingested  to  see  if  the  urine  specific  grav- 
ity becomes  high  again.  To  illustrate,  in  profuse  parenchymatous 
nephritis  or  large  lesions  which  occupy  almost  all  the  kidney,  where 
the  urine  is  of  low  specific  gravity,  such  kidneys  are  supposed  to 
be  unable  to  secrete  urine  whose  gravity  is  of  a  marked  higher 
gravity. 

Where  it  is  practical  in  any  given  case  more  than  one  of  these 
tests  should  be  tried,  so  that  the  results  of  one  may  check  up  the 
findings  of  the  others.  Particularly  true  is  this  in  tuberculosis  of 
the  kidney.  It  is  becoming  more  and  more  recognized  that  tuber- 
culosis of  the  kidney  either  directly  involves  both  kidneys  or 
while  one  kidney  may  show  the  active  lesions  of  it,  the  other 
kidney  is  very  prone  to  show  at  least  the  evidence  of  some  simpler 
inflammatory  process.  This  matter  will  be  again  referred  to  under 
the  subject  Tuberculosis  of  the  Kidney. 

It  should  be  borne  in  mind  that  when  it  is  practical  to  carefully 
carry  out  these  tests  a  great  aid  is  furnished  by  their  findings  in  a 
certain  proportion  of  cases.  Just  how  great  it  is  hard  to  state. 
The  evidence  given  by  the  ordinary  laws  of  surgical  procedure 
should  take  precedence  over  the  evidence  fm-nished  by  these  tests. 
This  particularly  refers  to  septic  conditions  associated  with  kidney 
abscesses. 

Sometimes  it  is  impossible  to  catheterize  the  kidneys  in  these 
cases.  Under  such  conditions  information  must  be  obtained  from 
the  twenty-four-hour  urine,  general  examinations  of  the  blood, 
and  such  procedures  as  the  estimation  of  nitrogen  in  the 
blood. 

We  also  wish  to  call  attention  to  the  more  recently  published 
tests  by  Herman  O.  Mosenthal  in  the  November,  19 15,  issue  of  the 
"Archives  of  Internal  Medicine,"  entitled  "Renal  Function  as 
Measm-ed  by  the  Elimination  of  Fluids,  Salt,  and  Nitrogen,  and 
the  Specific  Gravity  of  the  Urine."     Also  the  paper  of  Prof. 


PERMEABIUTY  OF  KIDNEY  ASSOCIATED  WITH  CATHETERIZATION    89 

Theodore  C.  Janeway,  of  Johns  Hopkins,  entitled  "Management  of 
Patients  with  Chronic  Renal  Disease." 

These  papers  contain  a  very  elaborate  set  of  statistical  tables 
of  the  reaction  of  normal  and  nephritic  individuals  to  the  so- 
called  "nephritic  test  meal,"  in  which  the  quantity  of  urine  elim- 
inated as  well  as  the  output  of  nitrogen,  sodium  chlorid,  and  the 
specific  gravity  have  been  carefully  estimated.  Space  does  not 
permit  our  going  more  into  detail,  but  we  feel  sure  that  it  will  be 
well  worth  while  for  those  interested  to  investigate  these  articles 
for  themselves. 


CHAPTER  III 

THE  CARE  OF  URETHRAL  INSTRUMENTS.-PREPA^ 

RATION  OF  PATIENT  FOR  OPERATION  AND 

AFTER-CARE 

THE  CARE  OF  URETHRAL  INSTRUMENTS 

Casper  has  well  stated  that  many  aseptic  conditions  in  the 
urinary  tract  may  be  rendered  septic  by  uncleanly  instrumenta- 
tion. Zuckerkandl  insists  that  catheterization  should  be  regarded 
in  the  light  of  a  surgical  operation,  and  that  preparations  for 
carrying  it  out  should  be  made  with  the  same  precaution  as  re- 
gards asepsis  as  are  observed  in  performing  operations  on  other 
portions  of  the  body.  It  may  be  stated,  also,  that  no  amount  of 
aseptic  care  regarding  the  hands  of  the  operator,  the  sterilization 
of  the  instruments,  or  the  preparation  of  the  field  of  operation 
will  render  a  trauma  in  the  urethral  tract  caused  by  instrumen- 
tation harmless.  The  ease  with  which  instrumentation  can  be 
carried  out  depends  largely  on  the  personality  of  the  operator. 
Some  men,  even  those  of  large  experience  are  apparently  regular 
bunglers  in  this  respect.  As  regards  cleanliness,  sterilization  of 
instruments,  and  preparation  of  the  field  of  operation,  however, 
personal  equation  is  not  a  factor,  since  these  procedures  can  be 
carried  out  by  any  operator  who  will  give  to  the  matter  the  time 
and  patience  required. 

Sterilization  should  not,  however,  be  carried  to  the  point  of 
excess.  In  following  the  instructions  laid  down  by  some  writers 
one  is  likely  to  produce  irritation  in  the  too  strenuous  effort  to 
secure  cleanliness.  Illustrative  of  this  overanxiety  to  obtain  an 
aseptic  field  is  the  much-recommended  practice,  previous  to  in- 
serting a  catheter  into  the  bladder,  of  washing  out  the  anterior 
urethra  with  a  solution  of  silver  nitrate  (one  or  two  grains  to  the 
ounce)  in  the  hope  of  rendering  sterile  any  shreds  that  may  remain 
in  contact  with  the  urethral  walls.  The  too  prolonged  applica- 
tion of  soap  poultices  for  the  purpose  of  loosening  up  the  layers 

90 


CARB   OF  URETHRAL  INSTRUMENTS  9 1 

of  the  superficial  epithelium  preparatory  to  operating  will  also 
prove  irritating. 

The  following  method  for  the  care  and  sterilization  of  instru- 
ments and  for  the  preparation  of  patients,  in  use  in  the  City  Hos- 
pital of  New  York,  has  stood  the  test  of  time  and  is  easily  fol- 
lowed. 

Soft-rubber  instruments,  such  as  soft-rubber  catheters,  are 
boiled  for  five  minutes  in  water  to  which  washing-soda  has  been 
added,  the  proportion  being  a  teaspoonful  of  soda  to  the  gallon. 
They  are  then  wrapped  in  steriUzed  gauze  and  kept  in  covered 
glass  jars.  Before  being  used  they  may  be  soaked  for  five  minutes 
in  I  :  20  phenol  solution,  this  to  be  washed  off  in  a  4  per  cent, 
boric-acid  solution. 

Not  only  the  soft-rubber  instruments,  but  also  silk  catheters 
and  bougies  may  be  boiled.  The  best  way  to  do  this  is  to  wrap 
them  in  a  piece  of  sterile  gauze  before  boiling.  When  boiled, 
remove  them  still  wrapped  in  the  gauze  with  the  fingers  and  place 
them  in  a  cool  solution.  Boiling  softens  the  lacquer  that  covers 
the  silk  instruments,  and  they  are  likely  to  suffer  indentation  if, 
while  hot,  another  instrument  is  allowed  to  come  in  contact  with 
them.  This  can  be  avoided  by  the  use  of  the  procedure  mentioned 
above.  Silk  instruments  may  also  be  disinfected  by  immersing 
them  for  five  minutes  in  a  i  :  20  phenol  solution  and  then  washing 
in  boric  acid  4  per  cent.,  or  they  may  be  soaked  in  a  i  :  10  of  i  per 
cent,  formaldehyd  solution.  It  is  recommended  by  many — and  has 
come  to  be  quite  the  general  custom — that  catheters  be  disinfected 
by  preserving  them  in  a  glass  jar  having  formaldehyd  at  the  bottom, 
formaldehyd  gas  being  generated ;  or  that  they  be  kept  continually 
soaking  in  a  0.5  per  cent,  formaldehyd  solution.  Experience  at 
the  City  Hospital  seems  to  show  that  when  either  rubber  or  silk 
instruments  are  continually  exposed  to  the  fumes  of  formaldehyd 
vapor,  or  are  immersed  in  a  solution  of  formaldehyd  of  a  strength 
of  0.5  per  cent,  or  stronger,  they  soon  become  worthless.  In  private 
practice  the  writers  have  disinfected  rubber  and  soft  instruments 
by  subjecting  them  to  the  action  of  formaldehyd  vapor  in  the 
sterilizer  described  below,  the  vapor  being  generated  by  the  heating 
of  a  formaldehyd  lozenge.  After  a  few  minutes  the  instrument  is 
removed  and  wrapped  in  sterile  gauze.     When  time  will  not  permit. 


92        CARE    OF    INSTRUMENTS   AND   PREPARATION    OF   PATIENT 

or  when  the  ordinary  forms  of  steriHzation  are  not  available,  a 
strong  solution  (2  to  4  per  cent.)  of  formaldehyd  may  be  used  and 
immediately  washed  off.  When  frequent  irrigations  are  to  be  made 
through  a  small  olive-pointed  gum  silk  catheter,  a  plan  to  be  rec- 
ommended in  private  practice  is  that  of  keeping  each  patient's 
instrument  separate,  thus  reducing  the  danger  of  carrying  infec- 
tion by  means  of  the  catheter  from  one  patient  to  another. 

Steel  instruments  are  sterilized  by  boiling  them  for  five  minutes 


Fig.  42. — Formaldehyd  sterilizer  for  catheters  and  small  instruments. 


in  a  solution  composed  of  a  teaspoonful  of  soda  to  a  gallon  of 
water;  they  are  then  dried,  wrapped  in  sterilized  gauze,  and 
placed  in  a  glass  jar  with  a  cover ;  they  may  be  then  soaked  in  a 
I  :2o  phenol  solution  for  five  minutes,  being  washed  off,  just  before 
using,  in  a  4  per  cent,  boric-acid  solution.  For  office  practice,  a 
small  steam  instrument-sterilizer  works  very  well. 

A  sterilizer  is  used  by  the  writers  in  which  steam  is  generated; 
it  is  heated  by  means  of  an  electric  worm  on  the  inside  of  the  ster- 
ilizer, which  is  brought  into  irnmediate  contact  with  the  water. 


care;  of  urethral  instruments 


93 


The  coil  running  from  this  apparatus  is  easily  attached  to  the 
electric-light  fixture,  and  the  instrument  has  proved  very  practi- 
cal. Care  should  be  taken,  however,  that  water  is  always  present 
in  the  sterilizer. 

Some  advise  the  addition  of  a  small  amount  of  ammonium 
chlorid  to  the  water  in  which  instruments  are  to  be  boiled.  A 
solution  of  mercury  bichlorid  (from  i :  5000  to  i :  3000)  is  a  useful 
disinfectant,  but  has  the  disadvantage  of  turning  metal  instru- 
ments dark  and  of  eroding  their  surfaces.  A  strong  solution  of 
formaldehyd  in  glycerin  may  also  be  used.     The  vapor  of  sulphu- 


Fig.  43.— Showing  electric  coil  for  boiling  water  in  sterilizer. 


rous  acid  has  been  employed  as  a  disinfectant,  but  the  simplest 
and  most  satisfactory  method  of  steriHzation  is  that  accomplished 
by  boiling  water. 

Cystoscopes  may  be  disinfected  by  soaking  them  in  i :  20  phenol 
solution,  care  being  taken  not  to  wet  the  inside  of  the  lenses; 
before  using,  the  instrument  may  be  washed  off  in  a  4  per  cent, 
boric-acid  solution.  Cystoscopes  are  best  disinfected  by  allowing 
them  to  remain  for  a  short  time  in  the  formaldehyd  vapor  gene- 
rated in  the  formaldehyd  sterilizer  previously  described. 


94        CARE    OF   INSTRUMENTS   AND    PREPARATION   OF   PATIENT 

After  use,  instead  of  allowing  it  to  lie  in  the  phenol  and  boric- 
acid  solutions,  the  cystoscope  may  be  again  subjected  to  the 
action  of  formaldehyd  gas,  washed  off  with  soap,  and  then  with 
a  solution  of  ether  or  lysol. 

Urethral  catheter  cystoscopes  are  difficult  to  clean,  and  evejry 
part  must  receive  separate  and  careful  attention. 

Cystoscopes  may  be  rubbed  with  green-soap  spirit,  and  after- 
ward with  alcohol  to  remove  the  green  soap.  Removable  parts 
should  be  boiled.  Fresh  solutions  for  each  disinfection  should 
be  made  up  from  a  stock  solution. 

The  general  rule  in  use  for  the  sterilization  of  cystoscopes  is 
applicable  to  lithotrites  and  their  evacuators  and  to  Kohlmann 
dilators.  Some  of  the  evacuators  on  the  market,  such  as  the  new 
Kraus,  the  Otis,  and  the  Chismore,  are  comparatively  easy  to 
sterilize,  whereas  others  are  so  constructed  as  to  present  greater 
difficulty. 

In  the  case  of  dilators  that  are  covered  with  rubber,  it  is  neces- 
sary to  sterilize  the  rubber  as  well.  This  may  be  done  in  various 
ways — by  immersion  in  solutions  of  phenol,  followed  by  immer- 
sion in  boric  acid;  by  the  application  of  formaldehyd  vapor, 
the  rubber  being  placed  over  one  of  the  combs  in  the  formaldehyd 
sterilizer,  according  to  the  method  shown  in  fig.  42.  By  keep- 
ing different  rubber  coverings  for  individual  cases  the  danger  of 
carrying  infection  is  minimized. 

Lubricants. — The  ideal  lubricant  for  the  passage  of  urethral 
instruments  is  yet  to  be  discovered.  If  it  were  desired  merely  to 
make  the  instrument  slip  into  the  urethra  with  ease,  vaselin  or 
the  various  oils  distilled  from  the  coal-tar  products  would  answer 
the  purpose.  '  As  is  well  known,  however,  these  substances  form 
a  coating  in  the  urethra  that  hinders  the  penetration  of  any  med- 
icament it  may  be  desired  to  apply  to  the  urethral  wall.  Gly- 
cerin with  boric  acid  is  an  excellent  lubricant.  For  this  purpose 
it  is  the  writers'  custom  to  use  Price's  English  Glycerin,  as  this 
seems  to  have  more  body  than  the  ordinary  glycerin  of  commerce. 
The  fact  that  glycerin  acts  as  an  irritant  on  some  persons,  com- 
bined with  the  fact  that  instruments  lubricated  with  it  will  not 
penetrate  quite  so  easily  as  those  lubricated  with  vaselin,  lessens 


CARE    OF   URETHRAL   INSTRUMENTS  95 

its  usefulness.  In  this  country,  at  present,  a  great  many  prepara- 
tions are  being  used  that  have  Irish  moss  as  a  base,  formaldehyd 
in  varying  proportions  being  added  for  its  antiseptic  properties. 
These  are  proprietary  articles,  and  in  most  cases  the  formulas  are 
not  definitely  given.  Their  disadvantage  Hes  in  the  fact  that  the 
jelly  of  the  Irish  moss  may  be  lumpy,  and  that  the  preparation  is 
not  so  easily  removed  from  instruments  as  is  glycerin.  In  private 
practice  the  writers  occasionally  use  a  preparation  called  formical, 
manufactured  by  John  Carl  and  Sons,  New  York  city;  in  this 
the  purified  chondrin  jelly  made  from  Irish  moss  is  combined  with 
a  certain  proportion  of  a  formaldehyd  solution. 

The  following  formula  (known  as  "  Katheterpurine")  is  pre- 
scribed by  Casper,  and  is  used  to  some  extent  in  this  country.  It 
has  occasionally  given  rise  to  irritation  of  the  urethra  when  the 
membranes  were  very  sensitive;  it  should  be  made  weaker: 

I^.     Oxycyanid  of  mercury, 0.246 

Glycerin, 20. 

Gum  tragacanth, 3. 

Water, 100      M. 

Kraus  uses  gum  tragacanth,  2.5  per  cent.,  glycerin,  10  per  cent., 
and  a  3  per  cent,  solution  of  phenol.  Owing  to  the  quantity  of 
water  it  contains,  this  can  easily  be  washed  off. 

Guyon's  pomade  is  made  of  equal  parts  of  glycerin,  water,  and 
soap. 

In  Germany  oxycyanid  of  mercury  is  being  used  extensively 
in  lubricants.  For  cystoscopes  the  glycerin  and  boric  acid  is 
probably  the  best.  Cleanliness  should  be  observed  as  regards  the 
bottles  or  other  receptacles  in  which  lubricants  or  substances  to 
be  used  for  purposes  of  irrigation  or  instillation  are  to  be  kept. 
Dust  should  not  be  allowed  to  accumulate  on  the  outside  or  on 
the  inside.  The  receptacles  should  be  of  a  type  that  can  be  boiled. 
Silver  nitrate  solutions  should,  of  course,  be  kept  in  covered  dark 
bottles. 


96        CARE    OF    INSTRUMENTS   AND    PREPARATION   OF   PATIENT 

PREPARATION  OF  PATIENT  FOR  OPERATION 

At  the  Citv  Hospital  the  method  of  preparing  patients  for 
operation  is  as  follows:  When  catheterization  or  simply  an  ex- 
amination of  the  urethra  is  to  be  carried  out,  the  glans  penis  and 
the  neighboring  parts  are  washed  off  with  a  bichlorid  solution 
1 :  5000  or  1 :  3000,  and  sterilized  towels  and  a  piece  of  sterilized 
gauze  placed  around  the  base  of  the  shaft  of  the  penis. 

As  previously  stated,  neither  in  hospital  work  nor  in  private 
practice  is  it  necessary  or  advisable,  previous  to  the  introduction 
of  an  instrument,  to  attempt  disinfection  of  the  urethra  by  means 
of  irrigations  or  disinfecting  fluids,  particularly  silver  nitrate 
solutions.  Neither  is  it  necessary,  as  a  routine  measure,  if  it  is 
desired  to  pass  fluid  beyond  the  compressor  urethrae  muscle,  to 
overcome  the  contraction  of  the  muscle  by  forcibly  distending  the 
anterior  urethra  by  fluid.  In  examining  the  bladder,  it  is  the 
writers'  general  practice  to  introduce  into  it  an  antiseptic  solu- 
tion, such  as  boric  acid  or  oxycyanid  of  mercury,  through  a  small 
olive-pointed  French  gum  catheter.  If  some  more  serious  opera- 
tion than  simple  examination  of  the  bladder  or  urethra  is  to  be 
performed,  the  method  of  procedure  is  as  follows: 

Before  operation  the   instruments   are,   of   course,   properly 
sterilized.     In  the  preparation   of   the   skin   some   distinction  is 


Fig.  44. — Plate  to  secure  catheter  in  suprapubic  drainage. 

made  as  to  whether  the  operation  is  one  in  the  neighborhood  of 
the  kidney  or  such  a  one  as  suprapubic  cystotomy ;  or  an  operation 
on  the  external  genitals,  testicles,  or  a  perineal  section  is  to  be 
made.  In  the  former  the  patient  is  scrubbed  up,  the  field  of  opera- 
tion is  washed  with  soap  and  water,  followed  by  alcohol,  the  sur- 
face scrubbed  with  alcohol  and  ether,  and  a  dry  dressing  is  applied. 
At  the  time  of  the  operation,  without  any  further  washing,  tincture 
of  iodin  is  painted  over  the  site  of  the  incision  and  allowed  to  dry 
before  the  cut  is  made.     Following  the  operation  in  many  condi- 


PREPARATION   OF   PATIENT   FOR   OPERATION 


97 


tions  it  is  wise  to  paint  the  inside  of  cavities  with  the  same  solution 
of  iodin  as  used  on  the  surface  of  the  skin.  After  operation  on  the 
kidneys  sterile  gauze  or  dry  sheet  gauze  is  applied,  this  being 
covered  with  folded  gauze;  next  a  binding  dressing  is  applied  con- 
sisting of  absorbent  cotton  placed  between  two  pieces  of  sterile 
gauze,  and  this  is  covered  with  a  many-tailed  bandage,  and  if  a  tube 
is  introduced  additional  dressing  is  required.  In  operations  on 
the  lower  genitals,  on  account  of  its  occasional  irritating  effects  on 
the  skin,  tincture  of  iodin  is  not  used;  the  patients  may  be 
scrubbed  up  just  before  operation.  In  the  preparation  of  a  patient 
for  perineal  section  alcohol  and  ether  should  not  be  used  about  the 
genitals,  but,  instead,  bichlorid  i  :  2000  should  be  employed. 

For  suprapubic  section  the  field  of  operation  is  also  prepared  as 
in  the  manner  above  described.  If  a  drainage-tube  is  introduced 
through  the  su- 
prapubic open- 
ing into  the 
bladder  and  it 
drains  well,  the 
dressing  need 
be  changed  but 
once  a  day ; 
where  there  is 
much  leakage 
around  the 
tube,  the  dress- 
ing should  be  changed 
more  frequently.  Strip 
gauze  should  be  placed 
around  the  tube,  covered 
by  plenty  of  fluff  gauze, 
and  a  combined  dressing 
with  a  hole  in  the  center 
applied,  being  retained 
in  place  by  strips  of  adhesive  plaster  over  and  on  each  side  of  the 
tube.  If  no  tube  is  inserted  in  the  suprapubic  opening,  or  after 
removal  of  the  tube,  it  is  necessary  to  change  the  dressing  every 
three  or  four  hours.  Frequent  change  of  dressings  should  follow 
7 


Fig.  45. — Dressing  for  perineal  section. 


98        CARE    OF   INSTRUMENTS  AND   PREPARATION   OF  PATIENT 

suprapubic  cystotomy  to  prevent   the  formation  of  suprapubic 
fistula. 

In  operations  on  the  testicle  the  dressing  consists  of  fluff  gauze 
placed  over  the  wound,  combined  dressing  over  this,  and  a  hand- 
kerchief bandage  support  covering  all.  This  handkerchief  ban- 
dage support  or  triangular  bandage  is  very  serviceable,  and  is 
probably  so  well  known  that  a  description  is  unnecessary. 

Zuckerkandl  advocates  cleansing  the  pubes,  glans  penis,  and  mea- 
tus with  soap  and  water,  fo  lowed  by  a  bichlorid  wash,  and,  as 
before  stated,  washing  out  the  anterior  urethra  with  a  silver  nitrate 
solution  1 :  2000,  so  as  to  render  any  shreds  that  may  be  present 


Fig.  46. — Dressing  for  perineal  section. 

in  the  anterior  urethra  antiseptic;  these  shreds  would  otherwise, 
if  washed  back  into  the  bladder,  start  up  an  inflammatory  process. 
He  advises  that  catheters  be  not  steriHzed  until  immediately 
before  use.  His  method  of  applying  the  spica  bandage  over 
the  shaft  of  the  penis,  over  the  glans,  running  down  on  to  the 
shaft  of  a  retention  catheter,  the  other  end  of  the  catheter 
being  in  a  container  passed  through  sterile  cotton  in  its  neck,  has 
been  elsewhere  described.  He  considers  that  retention  catheters 
will  occasionally  start  up  not  only  a  urethritis,  but  a  diphtheric 
inflammation  of  the  urethra  as  well. 

For  bladder  washings  he  recommends  oxycyanid  of  mercury 


PREPARATION   OP  PATIENT   FOR   OPERATION  99 

1 :  5000  in  place  of  boric  acid.  He  considers  that,  antiseptic  bladder 
washings  before  the  introduction  of  such  an  instrument  as  a  cys- 
toscope  will  sometimes  obviate  the  necessity  of  resorting  to  anti- 
septic bladder  washings  after  the  removal  of  the  instrument. 
His  suggestions  as  regards  the  sterilization  of  instruments  before 
performing  lithotrity  are  of  value.  He  recommends  that  the  pumps 
be  steriUzed  and  placed  in  bottles  filled  with  bichlorid  solution, 
where  they  should  be  left  until  required.  Just  before  opera- 
tion the  bichlorid  can  be  removed  and  boric  acid  solution  substi- 
tuted as  a  washing-out  fluid.  He  quotes  Guyon  as  advocating 
silver  nitrate  i :  5000  for  sterilizing  the  pumps.  Kraus  has  invented 
a  glass  pump  that  is  now  on  the  market  that  should  be  easily 
rendered  sterile. 

The  measures  advocated  by  Zuckerkandl  for  preparing  the 
patient  for  the  operation  of  litholapaxy  are  as  extensive  as  those 
followed  when  a  serious  operation  is  to  be  performed.  Beginning 
with  the  usual  bichlorid  solution,  soap  poultices,  etc.,  disinfec- 
tion of  the  hands  of,  and  the  wearing  of  sterile  clothes  by,  the 
operator,  he  recommends  the  prolonged  washing-out  of  the  urethra 
and  bladder  with  the  boric-acid  solution  before  the  lithotrite  is 
introduced;  his  general  recommendation  as  regards  the  frequent 
washings  of  the  bladder  during  litholapaxy  are  somewhat  at  vari- 
ance with  the  recommendations  of  Chismore,  quoted  elsewhere. 
Zuckerkandl,  who  has  written  extensively  on  asepsis  in  connec- 
tion with  surgery  of  the  urinary  organs,  recommends  that,  even 
for  so  simple  an  operation  as  urethrotomy,  the  antiseptic  details 
should  be  the  same  as  in  operations  of  greater  consequence. 

Anesthesia. — As  regards  general  anesthesia,  our  experience  has 
been  that  the  best  results  are  obtained  when  it  is  induced  either 
by  the  drop  method,  or  with  a  combination  of  nitrous  oxid  and 
ether,  as  with  the  Gwathmey  inhaler,  oxygen  gas,  and  ether. 
The  reader  is  referred  to  general  instructions  on  the  subject  of 
anesthesia  a  little  later  on  following  the  consideration  of  spinal 
anesthesia  and  following  methods  of  local  anesthesia.  Anesthesia 
through  intravenous  injection  is  being  practised  to  some  extent 
in  Russia,  but  has  never  been  attempted  by  us,  nor,  so  far  as  we 
know,  have  many  reports  on  that  method  been  published  in  this 
country. 


lOO     CARE    OF   INSTRUMENTS   AND   PREPARATION   OF   PATIENT 

Rectal  anesthesia  is  becoming  increasingly  popular,  but  we  have 
not  employed  it  as  yet  because  of  its  apparent  uncertainty  of 
dosage. 

Spinal  Anesthesia. — This  method  of  procedure,  though  so  popu- 
lar at  the  present  time  among  many  surgeons  in  this  country,  we 
strongly  advise  against.  The  main  advantage  claimed  for  it, 
which  is  of  apparent  credit,  is  that  it  is  less  irritating  to  the  kidney 
than  ether  and  chloroform.  This  is  more  than  offset  by  the  dis- 
advantages associated  with  its  use.  The  death-rate,  though  low, 
we  believe  to  be  higher  than  that  following  either  ether  or  chloro- 
form. Our  personal  experience  with  it  has  been  unfortunate. 
Another  and  very  important  objection  urged  against  it  by  one  of 
the  foreign  observers  is  that  in  case  of  any  unpleasant  symptoms 
associated  with  its  administration,  the  surgeon,  through  the  nature 
of  the  anesthesia,  is  unable  to  control  the  situation  to  any  extent 
and  administer  any  emergency  treatment,  as  can  be  done  with 
general  anesthetics  introduced  in  the  usual  way. 

Local  Anesthesia. — While  we  are  opposed,  as  mentioned  above, 
to  the  use  of  spinal  anesthesia  for  the  reasons  given,  we  are  heartily 
in  accord  with  the  workers  who  are  endeavoring  to  extend  the  field 
of  local  anesthesia.  Local  anesthesia  for  operations  on  the  urinary 
system  are  becoming  more  and  more  popular,  and,  we  believe,  de- 
servedly so.  These  procedures  can  be  administered  in  two  general 
ways:  the  infiltration  method,  by  which  the  conductability  of  the 
nerves  emerging  from  the  spine  are  affected,  and  the  direct  local 
injection  method.  Ordinarily  both  these  procedures  can  best  be 
carried  out  with  the  solution  of  Reel  us,  the  formula  of  which  is 
as  follows : 

Normal  salt  solution,  loo  gm.;  novocain,  50  e.g.;  adrenalin 
(i  :  1000  solution),  25  drops. 

One  c.c.  should  contain  \  drop  of  adrenalin. 
Where  small  quantities  only  are  required  locally,  in  such  minor 
operations  as  circumcision  and  simple  skin  incisions,  a  2  per  cent, 
cocain  solution  is  recommended. 

Conduction  Anesthesia  in  Genito-urinary  Surgery. — We  recom- 
mend the  following  works  to  be  carefully  studied  by  every  surgeon 
who  is  interested  in  this  method  of  procedure,  as  space  scarcely 
permits  us  to  give  all  the  necessary  details  the  following  out  of 


PREPARATION    OF    PATIENT    FOR    OPERATION  lOI 

which  will  be  attended  with  the  best  results.  The  two  works  rec- 
ommended are,  "Local  Anesthesia:  Its  Scientific  Basis  and  Prac- 
tical Use,"  by  Prof.  Dr.  Heinrich  Braun,  translated  by  Percy 
Shields,  M.  D.,  A.  C.  S.;  "Local  and  Regional  Anesthesia,"  by 
Carroll  W.  Allen,  M.  D.  (W.  B.  Saunders  Co.,  Phila.). 

Conduction  anesthesia  is  recommended  by  Braun  for  opera- 
tions on  the  kidney,  on  which  he  has  performed  several  using  the 
technic  of  Kappis.  "Three  nephrotomies  were  performed  in  the 
following  manner  (Figs.  47  and  48).  In  each  of  the  cases  it  was 
possible  to  determine  the  exact  extent  of  the  anesthesia.  The 
eighth  to  twelfth  dorsal  nerves  were  each  blocked  with  5  c.c.  of  i 
per  cent,  novocain-suprarenin  solution.  The  points  of  entrance 
were  placed  in  a  line  continuous  with  the  outer  edge  of  the  quadra- 
tus  lumborum  muscle.  Another  point  was  marked  on  the  outer 
edge  of  the  quadra tus  muscle  at  the  crest  of  the  ilium.  From  this 
point  and  the  point  marked  for  the  twelfth  dorsal  a  strip  of  tissue 
extending  to  the  kidney  fat  was  infiltrated  thoroughly  with  about 
75  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution.  No  further 
injections  or  circuminjections  were  necessary,  as  the  anesthesia  of 
the  skin  was  extensive,  as  shown  in  Figs.  47  and  48.  The  opera- 
tions were  absolutely  painless,  were  performed  upon  lean  persons, 
and  the  kidney  was  easily  accessible.  The  luxation  of  the  kidney 
was  painless.  There  is,  therefore,  every  reason  to  believe  that  local 
anesthesia  will  soon  be  used  for  kidney  surgery." 

For  blocking  the  nerves,  generally  speaking,  the  procedure  is  to 
insert  the  needle  back  of  the  lumbar  arch,  so  that  the  nerves  can  be 
deadened  as  they  emerge  from  their  foramen.  For  the  infiltration 
into  the  skin  and  muscles  two  injections  are  made  in  three  planes, 
one  plane  to  reach  the  deep  muscles  as  far  as  the  periosteum,  a  more 
superficial  plane  for  the  cellular  tissue,  and  a  third  for  the  skin. 
Attention  is  again  called  to  the  necessity  of  reading  the  two  vol- 
umes above  mentioned. 

The  above  method  can  be  used  for  the  kidney  and  ureter.  Con- 
ductability  anesthesia,  either  by  itself  or  associated  with  direct 
local  anesthesia  methods,  where  the  ptu-pose  is  to  deaden  the  nerve 
of  the  prostate  and  bladder,  is  best  performed  through  what  is 
called  the  parasacral  method,  in  which  the  nerves  lower  down  the 
spine  than  for  kidney  operations  are  deadened.     Investigators  are 


I02      CARE    OF    INSTRUMENTS   AND    PREPARATION    OF    PATIENT 


PREPARATION    OF   PATIENT   FOR    OPERATION  103 

referred  to  the  books  previously  mentioned  for  the  details  of  that 
procedure.  Personally  we  have  not  found  it  necessary,  and  are  in- 
clined to  the  belief  that  for  the  removal  of  prostates  or  even  bladder 
tumors,  save  in  exceptional  cases,  direct  local  anesthesia  methods 
are  all  that  are  required.  It  has  been  used  by  us  for  such  opera- 
tions as  prostatectomy.  According  to  the  method  of  Legueu 
(Journal  d'Urologie,  19 14,  vol.  v),  the  amount  of  the  Reclus  solu- 
tion that  is  used  for  a  prostatectomy  is  from  60  to  80  grams,  and 
for  the  wall  including  the  opening  of  the  bladder,  60  to  70  grams  of 
the  solution — in  all,  130  to  140  grams  of  the  solution.  Total  quan- 
tity of  the  anesthetic  is  0.60  to  0.80  e.g. 

A  slight  amount  being  injected  into  the  skin  over  the  rectus 
muscle  in  the  plane  in  which  the  incision  is  made,  the  incision  is 
carried  down  to  the  bladder  wall.  When  the  bladder  wall  is 
reached  inject  8  or  lo  gm.  of  the  solution,  diffusing  it  from  right  to 
left  into  the  thickest  part  of  the  bladder  wall.  Also  place  lo  to  20 
c.c.  of  the  solution  mixed  with  the  liquid  used  for  distending  the 
bladder.  With  the  bladder  opened,  the  fingers  of  the  left  hand  are 
placed  gently  over  the  prostate.  Into  the  prostate  is  injected  in 
the  line  of  cleavage  through  seven  or  eight  different  punctm-es,  for 
each  puncture  5,  7,  or  10  c.c.  of  the  solution,  according  to  the  size 
of  the  prostate. 

Legueu  had  some  special  needles  constructed  (Fig.  49),  20  to 
30  cm.  long,  of  different  angles  and  of  such  thickness  that  they  can- 
not be  easily  broken.  One  of  these  needles  has  a  large  curve  to  it 
to  fit  the  cirrvature  of  the  large  lobes  of  the  prostate;  for  the  sides 
and  the  anterior  angles  he  uses  a  shorter  right-angled  needle. 
The  direction  of  the  needle  is  guided  by  the  two  fingers  which  do 
not  quit  the  bladder  during  the  duration  of  the  anesthesia.  If  the 
needle  by  mistake  is  stuck  into  the  middle  of  the  enlargement,  the 
assistant  who  presses  the  piston  encounters  great  resistance.  If 
this  happens  the  position  of  the  needle  should  be  changed,  and  when 
it  is  well  placed  the  liquid  penetrates  easily.  When  the  periphery 
of  the  prostate  has  been  anesthetized,  two  punctures  are  made  into 
the  intraprostatic  urethra  to  analgesize  those  regions  where  it  is 
necessary  to  tear  across  the  urethra. 

A  few  minutes  after  the  injection  is  ended  operation  can  be 
proceeded  with  without  pain. 


I04     CARE   OF    INSTRUMENTS   AND    PREPARATION   OF   PATIENT 


Fig.  4g. — Legueu's  needles. 


Allen  follows  Legueu's  method  in  the  work  previously  referred 
to  except  that  he  has  no  special  needles  constructed. 

The  illustration   (Fig.  50)   shows  very  clearly  the  methods  of 


PREPARATION    OF    PATIENT   FOR   OPERATION 


105 


both  Allen  and  Legueu.  There  are  two  or  three  practical  points 
which  we  have  noticed  which  may  be  referred  to  in  this  connection. 
One  is  that  it  is  necessar\'  to  have  a  finger  in  the  rectum  as  well  as 
two  fingers  of  the  other  hand  touching  the  prostate  in  the  bladder 


Fig.  50. — Local  anesthesia  for  removal  of  the  prostate  (after  Allen). 

to  prevent  the  danger  of  the  needle  being  pushed  through  into  the 
rectal  wall.  By  doing  this  the  needle,  even  if  if  it  has  to  be  pushed 
into  the  prostatic  sheath  to  some  extent  by  the  assistant,  can  be 
guided  in  its  direction.  We  have  not  noticed  any  great  obstruction 
to  the  flow  of  the  fluid  even  when  the  prostate  itself  has  been  pene- 
trated by  the  needle.  A  very  few  minutes  after  injection  of  the 
fluid  the  prostate  becomes  absolutely  insensible,  and  although  the 
patient  may  complain  and  groan,  it  is  very  possible  that  it  may  be 


I06    CARE   OF   INSTRUMENTS   AND    PREPARATION   OF   PATIENT 

due  more  to  nerve  shock  than  to  actual  pain.  In  making  the 
original  incision  through  the  skin  a  small  needle  should  be  used  to 
deaden  the  skin  and  cellular  tissue,  as  its  insertion  causes  less  pain. 

While  we  are  inclined  to  strongly  endorse  and  recommend  the 
above  procedm-e,  it  should  not  be  forgotten  that  by  whatever 
method  such  an  operation  as  prostatectomy  is  performed,  there  is 
bound  to  be  more  or  less  after-shock  to  the  system,  and  when  re- 
quired the  application  of  hot- water  bottles,  the  installation  of  the 
Murphy  drip,  or  stimulants  should  be  resorted  to  in  a  manner  simi- 
lar to  what  they  would  be  if  general  anesthesia  had  been  used. 

As  previously  stated,  operations  on  the  scrotum,  including  cas- 
tration and  for  circumcision,  can  be  carried  on  by  direct  local 
injection  anesthesia.  For  perineal  section  we  have  used  direct 
local  injection  anesthesia  with  good  results,  which  can,  if  desired, 
be  supplemented  by  the  parasacral  infiltration  methods  of  Braun. 

Also  concerning  anesthesia  in  connection  with  operations 
on  the  genito-urinary  organs  the  same  general  rules  apply  as  to 
anesthesia  for  surgical  operations  on  other  portions  of  the  body. 
It  will  be  well  constantly  to  bear  in  mind  that  ether  and  chloro- 
form to  a  more  or  less  extent  have  a  poisonous  effect  upon  the 
system,  and  particularly  upon  the  kidneys,  as  has  been  abun- 
dantly proved  by  many  investigators.  One  of  the  prime  objects 
in  the  induction  of  all  anesthesia  is  to  do  away  with  the  reflexes. 
The  more  confidence  can  be  inspired  in  the  patient  the  less  amount 
of  anesthesia  will  be  required  to  overcome  these  reflexes. 

Not  infrequently  it  will  be  found  wiser,  on  account  of  the 
mental  effect,  to  apply  as  few  preliminary  dressings  as  possible 
to  the  individual  before  placing  him  on  the  table.  Ordinarily, 
in  patients  with  good  courage,  the  anesthetic  had  better  be  ad- 
ministered in  the  operating-room,  and  as  short  a  time  as  possible 
should  elapse  before  the  operation  is  commenced. 

Quite  a  large  proportion  of  patients  requiring  operation  on  the 
genito-urinary  system  are  individuals  in  advanced  years.  Cere- 
bral hemorrhage  not  infrequently  follows  immediately  after  or 
within  a  few  months  of  such  an  operation  as  prostatectomy. 
As  has  been  noticed  by  Albarran,  the  blood-pressure  is  a  good 
index  in  many  cases  of  the  condition  of  the  arteries,  and  it  is 
ordinarily  inadvisable  to  operate  on  the  kidneys  or  prostate  of  an 


PREPARATION   OF   PATIENT   FOR   OPERATION  I07 

individual  with  a  blood-pressure  of  over  220  until  at  least  an  at- 
tempt has  been  made  to  reduce  the  pressure  by  appropriate  treat- 
ment several  days  previous  to  the  operation.  For  this  purpose 
physical  rest  together  with  the  application  of  such  curative  thera- 
peutic remedies  as  may  be  indicated  is  advised.  It  should  be 
remembered,  however,  that  a  high  blood-pressure  is  often  to  a 
considerable  extent  compensatory. 

Following  severe  operations  on  the  genito-urinary  tract  little 
can  be  done  to  aid  in  overcoming  the  nausea  following  the  anes- 
thesia. The  use  of  a  hypodermic  of  morphin  is  suggested  when 
pain  requires  its  administration.  The  early  administration  of 
hot  liquids  in  considerable  quantities  is  highly  recommended 
not  only  for  its  effect  in  washing  out  the  stomach,  but  with  the 
idea  of  early  stimulation  of  the  secretory  powers  of  the  skin,  so 
as  to  reUeve  to  some  extent  the  work  required  to  be  done  by  the 
kidney.  Herb  teas  of  various  kinds  have  been  found  useful  for 
this  purpose.  A  hot  infusion  of  dried  violet  flowers  has  been  long 
used  for  this  purpose  by  one  of  us,  and  also  infusions  of  dog 
grass  and  uva  ursi  will  be  found  useful.  When  pain  does  not  re- 
quire the  administration  of  morphin  the  fluidextract  of  passaflora 
and  the  use  of  ignatia  has  been  found  by  us  more  useful  in  con- 
trolling any  nervous  symptoms  that  may  exist  than  the  more 
frequently  used  hypnotics  or  strong  nerve  sedatives. 

Sometimes  a  better  result  is  obtained  in  placing  the  patient 
recovering  consciousness  behind  a  screen,  the  attendant  observing 
the  patient  from  time  to  time  from  the  top  of  it,  rather  than  sitting 
by  the  bedside.  There  is  less  apt  to.be  vomiting  and  nausea  on 
account  of  the  increased  mental  calmness. 

The  custom  in  severe  operations  on  the  urinary  tract  to  ad- 
minister for  several  days  previous  to  the  operation  large  quan- 
tities of  water  with  or  without  one  of  the  ordinary  antiseptics, 
like  salol  or  urotropin,  is  ordinarily  to  be  recommended. 

Following  operations  pneumonia  is  to  be  seen  in  two  forms. 
One  form  comes  on  immediately  after,  within  twenty-four  to  forty- 
eight  hours  subsequent  to  the  operation,  and  may  be  due  to  a  pro- 
found septic  condition  of  the  patient  at  the  time  of  the  operation, 
or  not  infrequently  is  due  to  too  much  exposure  to  cold  or  wet 
while    under   the    anesthesia.      The    other   form   of   pneumonia 


I08     CARE   OF    INSTRUMENTS   AND    PREPARATION   OF   PATIENT 

is  apt  to  follow  a  week  or  ten  days  subsequent  to  operation,  par- 
ticularly in  elderly  people.  This  is  probably  not  infrequently 
due  to  carelessness  connected  with  the  nursing,  through  which 
patients  have  become  exposed  to  draughts. 

Following  severe  operations  on  the  urinary  tract  there  is  gener- 
ally some  diminution  in  the  quantity  of  urine  passed  through  the 
first  twenty-four  to  forty-eight  hours.  If  this  continues  the 
flow  of  urine  should  be  stimulated  by  the  use  of  diuretics  or  such 
other  medical  treatment  which  seem  to  be  indicated  for  the 
exigencies  of  the  individual  case.  For  anuria,  or  the  complete 
suppression  of  urine,  hot  compresses  or  a  poultice  of  digitalis 
leaves  should  be  applied  to  the  lumbar  region.  Subcutaneous 
injection  of  saline  solution  together  with  the  use  of  high  salt  ene- 
mas is  also  recommended,  and  in  desperate  cases  nephrotomy  or 
drainage  of  the  kidney  pelvis  while  the  symptoms  of  intoxication 
last.  As  a  preventive  of  anuria  following  operation  proctoclysis 
by  the  Murphy  drip  is  of  high  value.  Through  this  method  20 
to  200  drops  a  minute  of  a  saline  solution  are  allowed  to  flow  into 
the  rectum  at  very  slight  pressure ;  a  uniform  temperature  of  the 
fluid  in  the  rectum  of  100°  F.  is  desirable.  To  obtain  this  uniform 
temperature  it  is  necessary  to  regulate  the  temperature  of  the 
fluid  in  the  container  to  the  rapidity  of  the  flow;  160°  F.  is  re- 
quired for  the  fluid  in  the  retainer  if  a  flow  of  20  drops  a  minute 
at  the  right  temperature  in  the  rectum  is  desired.  A  tempera- 
ture of  138°  to  140°  F.  in  the  container  for  a  flow  of  200  drops 
a  minute.  These  figures  are  taken  from  a  table  prepared  by 
Dr.  R.  C.  Kemp  of  New  York.  Two  factors  deserve  attention, 
one  is  to  keep  the  fluid  in  the  container  at  as  even  a  temperature 
as  possible;  the  other  that  the  rectal  tube  should  not  be  removed 
for  a  half  hour  or  more  after  the  container  has  become  empty, 
so  as  to  prevent  the  escape  of  several  ounces  of  fluid  which  other- 
wise the  rectum  is  liable  to  contain.  The  rectal  tube  should  be 
introduced  about  30  inches,  and  a  pint  to  a  quart  of  the  solution 
used  in  one  application. 

The  practice  of  permitting  elderly  patients  to  sit  up  in  bed 
on  the  second  or  third  day  following  such  operations  as  prosta- 
tectomy, as  has  been  advocated  by  many,  is,  in  our  experience, 
sometimes  unwise.      The  idea  in  so  doing  is  to  overcome  pulmo- 


PREPARATION   OF    PATIENT   FOR   OPERATION  109 

nary  congestion,  but  generally  elderly  feeble  people  do  better 
if  no  marked  change  in  position  is  insisted  upon  from  five  days 
to  a  week  following  the  operative  procedure 

Concerning  the  use  of  alcohol  and  tobacco  following  opera- 
tions, particularly  in  elderly  people,  their  administration  should 
be  regulated  to  a  considerable  extent  by  the  previous  habits  of 
the  individual  operated  upon.  It  is  a  mistake  to  attempt  to  change 
the  habit  of  many  years  following  severe  operative  procedures, 
and  in  such  cases  the  early  use  of  alcohol  and  tobacco  should  be 
permitted. 

The  most  important  positive  factor  to  always  have  in  mind  in 
operations  on  the  urinary  tract  of  the  elderly  is  drainage.  The 
two  important  negative  factors  is  to  prevent  pneumonia  and 
cerebral  hemorrhage,  both  of  which  topics  have  already  been 
discussed,  but  concerning  the  question  of  drainage  something 
more  remains  to  be  said.  It  should  be  considered  not  only  after 
operation,  but  before.     Ordinarily  the  ingestion  of  plenty  of  fluid 


Fig.  SI. —  Retention  ureter  catheters  for  drainage  of  the  pelvis  of  the  kidney:  2,  Conical 
lower  end  fitting  closely  to  a  small  sound  as  guide  (Albarran). 

to  wash  out  the  kidneys  is  wise.  In  cases  of  infection  of  its 
pelvis,  when  practical,  previous  lavage  through  a  ureter  catheter 
with  some  fluid,  as  nitrate  of  silver  i :  10,000,  may  put  the  kidney 
in  a  better  state  for  the  operation,  if  performed  daily  for  a  week 
before  operating.  While  the  drainage  of  the  bladder  for  a  week 
previous  to  many  operations  upon  it  or  the  prostate,  through  such 
a  procedure  as  a  retention  catheter,  not  only  tends  to  the  im- 
provement of  the  organ  to  be  operated  on,  but  thorough  drainage 
of  the  kidneys  tends  to  do  away  with  any  products  of  urinary 
absorption  which  may  have  accumulated  and  diminishes  the 
danger  of  urinary  suppression  following  it. 

The  proper  after-drainage  following  operations  on  the  kidney 
is  of  the  greatest  importance.     The  presence  for  some  days  when 


no    CARE   OF   INSTRUMENTS   AND   PREPARATION  OF  PATIENT 


possible  of  counter-drainage  through  a  retention  ureter  catheter 
may  be  mentioned.     Also  the  care  when  doing  nephrotomy  for 

kidney  abscess,  in  thoroughly  cleaning 
out  the  pockets  of  pus  that  may  be 
present,  will  have  much  to  do  to  ensure 
complete  healing  and  prevent  the  for- 
mation of  fistula.  The  after-results  fol- 
lowing such  an  operation  as  prostatec- 
tomy are  dependent  to  a  great  extent 
on  the  proper  drainage,  while  primary 
union  may  follow  a  cystotomy  where 
the  urine  is  clear  if  proper  drainage 
can  be  obtained  through  a  retention 
catheter. 

Our  personal  experience  and  that  of 
our  associates  with  retention  ureteral 
or  urethral  catheters  does  not  confirm 
the  good  results  reported  as  obtained 
through  their  use  abroad,  and  we  have 
not  been  able  to  use  very  large  ones 
for  the  ureter,  or  to  keep  them  in  for 
longer  than  thirty-six  hours  at  a  time 
on  account  of  incrustation,  while  in  the 
urethra  we  often  have  to  remove  them  on 
account  of  irritation.  This  latter,  we  be- 
lieve, is  due  frequently  to  the  poor  general 
condition  of  our  hospital  patients,  but 
through  increased  familiarity  with  these 
two  mentioned  procedures  on  the  part 
of  surgeons  it  can  be  expected  that  their 
application  can  be  made  more  frequent, 
and  that  they  will  greatly  aid  in  obtain- 
ing better  after-results. 

Albarran  uses  ordinarily  a  No.  6  ureter 
catheter  to  commence  with,  as  a  guide 
during  his  operations  on  the  ureter  or  the  kidney.  It  is  his  cus- 
tom to  insert  into  the  upper  end  of  this  ureter  catheter,  which  has 
been  introduced  through  the  meatus  of  the  urethra  to  the  pelvis 


Fig.  52. —  Long  ureteral  man- 
darin formed  of  two  pieces  which 
articulate.  Used  in  changing  ure- 
teral drainage  catheter  (Albarran). 


PREPARATION   OP   PATIENT  FOR   OPERATION  III 

of  the  kidney  (or  in  case  of  an  operation  upon  the  ureter,  through 
such  an  opening  in  the  ureter  as  may  have  been  made),  a  No.  12 
ureter  catheter;  then,  by  withdrawing  the  No.  6  through  the 
urethra,  the  No.  12  follows  it  along  the  urinary  canal  until  its 
end  emerges  from  the  urethral  orifice.  It  is  sometimes  allowed  to 
remain  as  a  kidney  or  ureter  drain  for  a  period  as  long  as  six  days 
without  removal.  Should  he  find  it  desirable  to  change  the  catheter 
during  that  period,  he  does  so  by  means  of  a  mandarin  in  two 
parts,  which  is  introduced  into  the  retention  ureter  catheter,  and 
over  which  a  new  ureter  catheter  is  inserted,  the  new  one  follow- 
ing the  one  already  in  place  from  its  superior  insertion  downward 
as  the  latter  is  removed. 

Continuous  bladder  irrigation  has  been  used  to  some  slight  ex- 
tent with  good  results  for  cystitis  and  is  used  by  some  operators 
following  prostatectomy.  Although  it  has  not  yet  come  into  gen- 
eral use,  we  believe  it  will  in  the  future  prove  a  valuable  aid.  It 
can  be  applied  through  a  double-current  catheter,  either  through 
a  perineal  or  suprapubic  opening. 


CHAPTER  IV 

EXAMINATION  OF  THE    URINE    AND  URETHRAL 
EXUDATE 

EXAMINATION  OF  THE  URINE 

The  technic  of  urinary  examination  is  now  so  fully  discussed 
in  numerous  special  text-books  that,  with  the  limited  space  at  our 
disposal,  it  seems  unnecessary  to  consider  this  subject  in  detail; 
our  attention  will,  therefore,  be  devoted,  instead,  to  a  considera- 
tion of  the  value  and  application  of  urinary  diagnosis. 

There  is,  perhaps,  no  field  of  diagnosis  in  renal  disease  in  which 
greater  error  may  result  than  from  the  making  of  isolated  urinary 
examinations,  though  they  may  seem  to  afford  the  most  accurate 
and  direct  evidence  as  to  the  action  of  the  kidneys.  This  possi- 
bility of  error  is  largely  the  result  of  the  fact  that  not  only  does 
the  normal  constitution  of  the  urine  vary  markedly  in  different 
subjects,  but  it  may  vary  also  in  the  same  subject  under  many 
differing  physiologic  as  well  as  pathologic  states.  The  urinary 
characteristics  are  also  very  largely  and  directly  dependent  upon 
the  nature  of  the  food  and  drink,  a  fact  that  is  too  frequently 
overlooked  in  estimating  the  significance  of  any  urinary  examina- 
tion. Finally,  it  should  not  be  forgotten  that  a  diagnosis  should 
never  be  based  solely  on  the  urinary  findings,  and  that  these  find- 
ings are  to  be  looked  upon  only  as  symptoms  and  considered  with 
all  the  clinical  aspects  of  the  case.  It  must  not,  moreover,  be 
overlooked  that  just  as  marked  variation  exists  in  the  urinary 
picture  as  in  any  other  of  the  symptomatic  manifestations  of 
diseases  of  the  urinary  passages. 

Collection  of  Specimen. — It  is  best,  whenever  practicable,  for 
the  physician  to  secure  the  specimen  himself,  receiving  the  same  in 
a  clean  vessel,  and,  when  desired  for  bacteriologic  examination, 
under  sterile  precautions.  Very  serious  errors  in  diagnosis  and  in 
subsequent  treatment  have  followed  a  lack  of  attention  to  these 
manifestly  important  details.  Unusual  foreign  substances  in 
the  urine  should  always  be  looked  upon  as  contaminations  until 
they  can  definitely  be  shown  to  have  actually  been  voided  by  the 
patient.     When  considerable  importance  is  to  be  attached  to  the 


EXAMINATION   OF    THE    URINE  II3 

urinary  analysis,  a  statement  of  the  patient's  diet  and  medication 
should  be  furnished  with  the  specimen.  In  every  case  the  speci- 
men selected  for  examination  should,  if  possible,  be  taken  from  the 
entire  twenty-four-hour  urine,  the  totaly  quantity  of  which  should 
further,  of  course,  have  been  determined. 

When  considerable  time  must  elapse  between  the  collection  of 
the  specimen  and  the  examination,  the  urine  should  be  kept  in 
the  ice-box  or  a  few  grains  of  chloral  should  be  placed  in  it. 
Chloroform  or  formalin  may  also  be  added  for  the  same  purpose. 

Amount.— The  amount  of  urine  passed  should  always  be  consid- 
ered in  conjunction  with  the  quantity  of  liquid  nourishment  taken 
and  also  with  the  water  excreted  by  the  bowels  and  skin.  Only 
when  these  factors  have  been  considered  may  the  quantity  of  urine 
passed  be  regarded  as  a  means  of  pointing  out  possible  disease. 
In  important  cases  a  fluid  and  urine  chart  is  very  useful,  since  it 
graphically  demonstrates  any  gross  retention  and  at  the  same 
time  is  a  most  excellent  control  of  the  effects  of  treatment  in 
local  or  general  edemas.  The  amount  of  urine  may  vary  normally 
between  800  c.c.  and  3000  c.c.  in  twenty-four  hours,  this  being 
dependent  somewhat  on  the  sex  and  the  body  weight;  a  fair 
statement  of  the  average  amount  would  be  about  1500  c.c.  Patho- 
logic polyuria  occurs  in  diabetes,  both  with  and  without  glycosuria, 
and  in  interstitial  nephritis.  A  temporary  polyuria  is  a  frequent 
accompaniment  of  many  nervous  and  mental  disorders,  of  shock, 
and  of  like  conditions. 

Decrease  in  the  amount  of  urine  is  found  in  practically  all  condi- 
tions where  blood  pressure  is  lowered,  as,  for  example,  in  various 
types  of  cardiac  insufficiency.  It  is  a  very  marked  symptom  of 
acute  nephritis,  where  it  may  amount  to  actual  suppression,  and 
it  is  also  seen  in  many  nervous  conditions,  as  in  some  cases  of 
hysteria,  epilepsy,  and  the  like.  As  has  been  stated,  it  is  of  the 
greatest  importance  always  to  consider  the  quantity  of  urine  ex- 
creted in  connection  with  the  amount  of  liquid  ingested  and  that 
excreted  by  other  emunctory  organs. 

Specific  Gravity. — The  specific  gravity  of  urine  is  very  closely 
associated  with  the  amount  excreted  and  with  the  total  solids 
thus  thrown  out  of  the  body.  It  may,  therefore,  be  taken  more 
or  less  accurately  as  a  measure  of  the  solids  excreted.  In  order 
that  conclusive  data  as  to  the  excretion  of  solids  may  be  drawn 


114  EXAMINATION    OF    URINE    AND   URETHRAL   EXUDATE 

from  an  examination  of  the  urine,  by  any  method,  it  is  absolutely 
necessary  that  the  entire  twenty-four  hours'  amount  be  collected 
and  the  specific  gravity  determined  from  this. 

Reaction. — The  reaction  of  the  urine  is  normally  acid.  It  may, 
however,  become  amphoteric,  neutral,  or  alkaline  under  the  in- 
fluence of  medication,  from  the  use  of  certain  foods,  and  under 
some  physiologic  as  well  as  in  many  pathologic  conditions.  In 
itself  the  reaction  of  any  individual  specimen  has  but  little  impor- 
tance. When,  however,  the  reaction  of  the  fresh  entire  twenty- 
four  hours'  specimen  is  altered,  the  cause  for  this  change  must  be 
ascertained.  For  example,  after  severe  nervous  strain,  especially 
if  prolonged,  the  urine  may  become  intensely  acid,  due  to  excessive 
excretion  of  acid  phosphates.  A  diet  almost  purely  vegetarian 
leads,  in  many  cases,  to  the  excretion  of  an  amphoteric  or  alkaline 
urine,  whereas  a  diet  rich  in  animal  food,  as  a  rule,  gives  rise  to  a 
highly  acid  urine.  Frequently  the  reaction  of  the  urine  may  cause 
more  or  less  marked  disturbances.  Thus  a  highly  acid  urine  may 
account  for  vesical  irritation  and  for  frequent  and  painful  urina- 
tion. Less  often  a  strongly  alkaline  urine  may  cause  similar 
manifestations.  Where  the  reaction  of  the  urine  only  is  at  fault, 
the  condition  is  usually  easily  corrected  by  giving  attention  to  the 
diet,  fluid  intake,  or  by  simple  corrective  medication. 

Urinary  Constituents 
Urea. — The  amount  of  urea  present  in  the  urinary  output  should 
be  determined  as  a  matter  of  routine  in  all  urinary  examinations, 
for  this  substance  is  the  most  important  element  given  off  as  a 
result  of  nitrogenous  decomposition  in  the  human  body.  Unfor- 
tunately, the  amount  of  urea  excreted  under  various  physiologic 
as  well  as  pathologic  states  varies,  being  largely  associated  with 
the  amount  of  nitrogen  thrown  out  in  the  form  of  other  nitrog- 
enous compounds,  such  as  uric  acid,  kreatinin,  xanthin  bases,  and 
the  like;  the  total  nitrogenous  metabolism  of  the  body  can  there- 
fore be  accurately  estimated  only  when  the  presence  of  all  these 
are  determined,  as  by  the  method  of  Kjeldahl.  For  comparative 
clinical  use  the  methods  of  urea  determination  as  obtained  by  the 
Doremus  or  the  Einhorn  ureometer  are  sufficiently  accurate  in  most 
cases.  The  amount  of  nitrogen  ingested  and  the  relative  amount 
excreted  with  the  feces  must  be  taken  into  consideration.  Tissue 
destruction  resulting  in  increased  urea  excretion  can  be  ascertained 


EXAMINATION    OF    THE    URINE  II 5 

only  when  comparison  of  the  amount  of  urea  excreted  is  found  to  be 
in  excess  of  the  relative  amount  of  chlorids  in  the  urine,  for  in  health 
the  chlorids  equal  about  one-half  the  amount  of  urea  excreted. 

Nearly  all  febrile  conditions,  and  whenever  excessive  tissue  waste 
is  taking  place,  are  accompanied  by  an  increase  in  urea  excretion. 
Urea  is  duninished  in  such  diseases  as  acute  yellow  atrophy,  Weil's 
disease,  and  in  other  conditions  where  serious  destruction  of  the 
liver  parenchyma  is  taking  place,  under  which  circumstances  am- 
monia compounds  appear  in  relatively  excessive  amounts. 

Uric  Acid. — Uric  acid  occurs  in  the  urine  only  as  a  result  of  the 
destruction  of  the  nucleins  of  the  food  or  of  the  body.  There  can 
be  but  little  doubt  that  the  amount  of  uric  acid  found  in  the  urine 
has  but  slight  clinical  significance  in  most  cases,  except  when 
due  to  the  high  acidity  of  the  urine  or  to  some  other  cause,  it  is 
precipitated  in  the  form  of  fine  crystals  that,  acting  as  foreign 
bodies,  may  give  rise  to  marked  local  irritation.  The  amount  of 
uric  acid  found  in  this  form  is,  however,  no  measure  of  the  quantity 
excreted,  for  crystals  may  be  found  abundantly  even  when  little  or 
no  uric  acid  remains  in  solution,  whereas,  on  the  other  hand,  no 
crystals  may  be  found  in  the  urinary  sediment  when  the  acid  may 
be  present  in  large  amounts  held  in  solution.  It  is  normally  present 
in  relation  to  urea  in  a  ratio  of  about  i :  60. 

A  relationship  between  numerous  clinical  manifestations  that 
are  commonly  known  as  the  uric  acid  diathesis  and  actual  uric 
acid  excretion  has  never  been  satisfactorily  established. 

Chlorids. — Under  normal  conditions  the  chlorids  of  the  urine  are 
a  measure  of  the  chlorids  present  in  the  food  ingested;  they  occur 
mostly  in  the  form  of  sodium  chlorid.  TJiey  are  diminished  in 
practically  all  acute  febrile  conditions,  particularly  in  lobar  pneu- 
monia and  in  many  forms  of  nephritic  diseases  where  the  amount 
of  water  excreted  is  also  diminished,  for  it  has  been  shown  that 
the  amount  of  chlorids  thrown  off  bears  some  relation  to  the  ex- 
cretion of  water;  hence  the  importance  of  restricting  the  intake 
of  sodium  chlorid  in  nephritic  diseases.  The  estimation  of  the 
amount  of  chlorids  in  the  urine  forms  a  fairly  accurate  estimate  of 
the  digestive  and  absorptive  powers  in  any  given  instance.  It 
should  be  remembered  that  in  some  cases  of  nephritis  chlorid  ex- 
cretion is  greatly  retarded. 

In  purely  clinical  studies  an  accurate  estimation  of  the  chlorids 


Il6  EXAMINATION    OF    URINE    AND    URETHRAIv   EXUDATE 

is  rarely  essential,  and  a  fairly  satisfactory  comparative  method 
is  that  afforded  by  adding  a  certain  number  of  drops  of  silver 
nitrate  to  a  definite  amount  of  urine,  and  observing  the  character 
and  density  of  the  precipitate  of  silver  chlorid  that  forms. 

Phosphorus. — The  presence  of  phosphoric  acid  in  the  urine,  like 
the  chlorids,  is  also  dependent  in  considerable  degree  on  the  quantity 
of  this  substance  taken  in  as  food,  only  a  small  amount  being  the 
result  of  tissue  destruction.  This  view  does  not,  however,  meet 
with  universal  acceptance.  Phosphorus  is  found  chiefly  in  the 
form  of  salts  of  sodium,  potassium,  calcium,  and  magnesium,  and  it  is 
chiefly  these  substances  that  give  the  acid  reaction  to  normal  urine. 

The  excretion  of  phosphorus  is  diminished  in  most  febrile  diseases, 
and  the  decrease  is  more  or  less  dependent  on  the  severity  of  the 
disease.  It  is  a  matter  of  common  clinical  observation  that  severe 
nervous  conditions  are  generally  associated  with  an  increased  out- 
put; in  leukemia  the  excretion  is  also,  as  a  rule,  greatly  augmented. 

The  detection  and  determination  of  phosphates  in  the  urine  are 
possible  only  by  the  usual  qualitative  and  quantitative  chemic  tests. 

Sulphur. — The  sulphur  found  in  the  urine  is  the  result  of  the 
breaking  down  of  albuminous  substances  in  the  body,  only  a  small 
amount  being  accounted  for  by  the  inorganic  salts  of  sulphuric 
acid  taken  in  the  food.  The  greater  amount  exists  in  the  form  of 
inorganic  salts,  known  as  preformed  sulphates;  whereas  the  remain- 
der occur  as  combinations  of  sulphur  and  certain  aromatic  bodies 
and  are  designated  as  conjugate  sulphates. 

The  sulphur  compounds  are  normally  found  increased  when 
tissue  decomposition  is  taking  place,  and  the  conjugate  sulphates 
are  increased  particularly  when  intestinal  fermentation  is  going 
on.  Certain  drugs,  such  as  morphin,  the  bromids,  and  the  salicy- 
lates, cause  an  increased  elimination  of  sulphur,  whereas  ingestion 
of  alcohol  results  in  a  diminution. 

Both  qualitative  and  quantitative  determinations  of  the  sulphur 
compounds  of  the  urine  depend  on  the  precipitation  of  barium  sul- 
phate; when  a  properly  prepared  solution  of  barium  chlorid  is 
added  to  the  urine,  the  sulphur  is  deposited  in  the  form  of  barium 
sulphate  and  the  precipitate  is  then  weighed. 

Albumin. — The  presence  of  albumin  in  the  urine  has  long  been 
regarded  as  indicating,  for  the  most  part,  disease  of  the  kidneys  or 
vascular  system;  cases  are,  however,  occasionally  met  in  which 


EXAMINATION    OF   THE    URINE  II 7 

albumin  appears  to  be  excreted  physiologically  in  the  urine.  This 
applies  in  a  general  way  only  to' specific  forms  of  albumin,  such  as 
egg-albumen  or  the  albumin  of  other  special  articles  of  diet.  From 
this  it  may  be  seen  that  the  amount  of  albumin  present  in  the  urine 
may  be  definitely  dependent  on  the  character  of  the  food  ingested 
and  on  the  condition  of  the  absorptive  and  digestive  functions.  In 
nephritis,  the  amount  of  albumin  excreted  must  not  be  taken  as  a 
measure  of  the  progress  of  the  disease,  although  this  is  verv  com- 
monly believed  to  be  the  case.  In  certain  forms  of  renal  disease, 
particularly  in  those  chiefly  characterized  by  the  production  of  scar 
tissue  in  the  kidneys,  the  amount  of  albumin  excreted  is  usually 
small,  and  therefore  cannot,  of  course,  be  regarded  as  a  measure 
of  the  gravity  of  the  case.  On  the  other  hand,  it  will  sometimes  be 
found  that  a  case  presenting  markedly  favorable  symptoms  may 
yet  persistently  show  large  quantities  of  albumin  in  the  urine. 
It  must,  therefore,  be  conceded  that  the  finding  of  albumin  in  the 
urine  has  but  sUght  value  beyond  that  of  aiding  in  diagnosis. 
Its  disappearance  in  no  way  indicates  that  the  disease  is  abating, 
nor  does  its  persistence  indicate  further  progress  of  the  disease. 
An  exception  to  this  rule,  however,  must  be  made  when  the  albu- 
min present  is  found  to  be  due  to  blood;  then  the  quantity  and 
fluctuation  are  often  of  great  prognostic  value. 

The  occurrence  of  special  forms  of  albumin  is  often  of  consider- 
able significance,  and  in  obscure  cases  detailed  chemic  investiga- 
tions will  prove  of  marked  service ;  thus  the  presence  of  Bence- 
Jones  albumin  is  apparently  definitely  diagnostic  of  multiple  mye- 
loma, the  chemic  reactions  determining  its  identity  are  simple 
and  easily  demonstrated. 

As  a  rule,  the  Heller  test,  made  with  cold  nitric  acid,  has  been 
found  one  of  the  most  satisfactory  for  the  routine  detection  of 
albumin.  When  doubt  exists  as  to  its  presence  or  absence,  other 
tests  should  be  employed,  the  potassium  ferrocyanid  test  being 
one  of  the  most  deHcate.  For  ordinary  clinical  purposes  the 
quantitative  determination  of  albumin  can  be  made  by  the  famil- 
iar Esbach  method,  which  gives  sufficiently  accurate  results. 

Sugar. — This  is  often  found  in  the  urine  of  entirely  normal 
persons  under  special  dietetic  conditions,  as  when  sugar  has  been 
taken  in  abnormal  quantities  or  when  special  forms  of  it,  to  which 
the  individual's  tissues  seem  to  be  intolerant,  have  been  ingested. 


Il8  EXAMINATION    OF    URINE    AND    URETHRAL    EXUDATE 

The  occurrence  of  lactose  in  the  urine  of  pregnant  or  lactating 
women  is  very  frequent.  Apparently  it  has  no  serious  signifi- 
cance. Certain  special  foods  or  drinks  may  also  occasionally 
induce  the  appearance  of  sugar  in  the  urine  even  though  they 
contain  no  sugar  in  themselves.  Thus,  in  a  case  under  the  ob- 
servation of  one  of  us,  sugar  appears  whenever  whisky  or  other 
concentrated  alcoholics  are  taken,  but  does  not  occur  in  this 
instance  after  the  ingestion  of  champagne  or  the  sweet  wines, 
nor  even  when  sweets  are  taken  in  excess.  When  large  quan- 
tities of  certain  forms  of  sugar  have  been  taken  and  small  quan- 
tities of  it  appear  in  the  urine,  this  may  in  most  cases  be  ignored 
as  an  indication  of  disease;  it  may,  however,  as  pointed  out  by 
von  Noorden,  signify  a  lessened  ability  on  the  part  of  the  tissues 
to  burn  up  sugar,  and  an  increased  inclination  toward  the  develop- 
ment of  diabetes.  The  early  detection  of  sugar,  then,  even 
when  apparently  of  physiologic  origin,  often  becomes  a  matter 
of  considerable  import  in  the  preventive  treatment  of  diabetes. 
For  a  more  complete  discussion  of  the  appearance  of  sugar  in  the 
urine  the  reader  is  referred  to  the  treatises  dealing  with  diabetes. 

Since  there  are  a  considerable  number  of  substances  that  may 
give  a  reaction  simulating  the  reduction  tests  with  Fehling's 
solution,  reliance  should  never  be  placed  on  this  test  alone, — at 
least  in  a  preliminary  examination, — ^but  the  fermentation  test  or 
that  with  phenylhydrazin,  preferably  the  former,  should  also  be 
employed.  Quantitative  tests  are  most  satisfactorily  made  with 
Fehling's  solution  or  with  Whitney's  reagent,  the  presence  of  other 
reducing  bodies,  of  course,  having  first  been  disproved  or  removed. 

Acetone. — Acetone  should  always  be  sought  for  in  cases  of  gly- 
cosuria, although  its  occurrence  is  not  limited  strictly  to  this 
state.  It  is  often  found  also  in  apparently  purely  physiologic 
conditions,  although  its  presence  is  usually  associated  either  with 
gastro-intestinal  or  hepatic  disturbance  or  with  true  diabetes. 
The  test  that  has  been  found  most  satisfactory  for  the  detection  of 
acetone  is  that  of  Lieben.  (A  few  cubic  centimeters  of  the  first  dis- 
tillate of  the  urine  are  treated  with  several  drops  of  dilute  solution 
of  iodopotassic  iodid  and  sodium  hydro xid,  when,  even  if  small 
quantities  of  acetone  are  present,  a  precipitation  of  iodoform  oc- 
curs.) In  cases  of  diabetes  considerable  amounts  of  acetone  are 
of  marked  prognostic  value  and  are  generally  of  grave  significance. 


MICROSCOPIC    EXAMINATION    OF   THE    URINE  II 9 

Indican. — Indican  occurs  in  the  urine  chiefly  when  absorption 
from  retained  intestinal  contents  is  taking  place  or  when  abnormal 
intestinal  fermentation  is  going  on;  it  is  therefore  seen  in  cases  of 
constipation  and  in  tyrotoxicon  and  other  forms  of  ptomain  poison- 
ing. It  is  found  in  greater  or  smaller  amounts  in  nearly  all  urines, 
and  is  of  importance  only  when  taken  in  consideration  with  other 
manifestations  of  abnormal  intestinal  absorption.  It  may  be 
detected  in  the  course  of  Heller's  test  for  albumin,  a  variegated 
brown  or  purple  line  forming  just  above  the  acid  zone.  A  more 
accurate  test  is  made  by  shaking  a  few  cubic  centimeters  of  the 
suspected  urine  with  a  solution  of  ferric  chlorid  with  hydrochloric 
acid,  to  which  a  small  quantity  of  chloroform  is  added,  which  then, 
on  separation,  takes  on  the  characteristic  blue  or  purple  color. 

Bile -pigments. — Bile-pigments  are  usually  found  in  the  urine 
in  cases  of  obstruction  to  the  common  duct,  when  hepatogenous 
pigmentation  is  present,  or  sometimes  when  extensive  destruction 
of  the  blood  is  taking  place.  It  is  manifest  chiefly  in  cases  of 
jaundice  due  to  any  cause.  In  marked  cases  it  is  easily  recognized 
by  the  deep  color  of  the  urine  and  by  its  power  of  staining  filter- 
paper  a  typical  bile  color.  It  may  also  be  detected  by  the  addition 
of  tincture  of  iodin  in  the  form  of  a  layer  above  the  urine  in  a  test- 
tube.  If  bilirubin  is  present,  an  emerald-green  color  will  form  at 
the  point  of  contact.  When  nitric  acid  is  added  to  the  urine  in  a 
test-tube,  as  in  the  ordinary  Heller's  test  for  albumin,  a  color  play, 
green  predominating,  will  result. 

Fat. — Fat  never  occurs  normally  in  the  urine.  It  is  found, 
however,  in  cases  of  extensive  destruction  of  the  fatty  tissues  of 
the  body,  notably  of  the  bone-marrow.  It  is  occasionally  seen 
after  the  administration  of  large  quantities  of  fat  either  by  the 
mouth  or  by  inunction.  The  term  chyluria  is  applied  to  a  condi- 
tion in  which  the  fat  present  in  the  urine  gives  it  a  milky  appear- 
ance. This  condition  is  present  most  frequently  in  cases  of  fila- 
rial infection,  though  it  may  also  occur  when  chyle  enters  the 
urine  through  fistulae  or  in  any  other  manner. 

MICROSCOPIC  EXAMINATION  OF  THE  URINE 
When  possible,  the  urine  should  be  thoroughly  centrifugated 
before  microscopic  examination  is  undertaken.     When  a  centri- 
fuge is  not  at  hand,  the  urine  may  be  allowed  to  stand  for  a  consid- 


I20 


EXAMINATION    OF   URINE   AND   URETHRAL   EXUDATE 


erable  length  of  time  in  a  conic  sedimenting  glass,  after  which  the 
material  collecting  at  the  bottom  may  be  pipeted  off  and  examined. 
The  urinary  sediment  must  always  be  considered  in  conjunction 
with  the  chemic  characteristics  of  the  urine;  thus  a  highly  acid 
urine  may  cause  a  precipitation  of  uric  acid,  even  though  this 
substance  is  present  only  in  normal  quantity.  On  the  other  hand, 
alkaline  fermentation,  which  may  take  place  entirely  after  the 
urine  has  been  voided,  ma}^,  unless  this  fact  is  known,  lead  to 
erroneous  conclusions  as  to  the  conditions  really  present  in  the 
urinary  tract. 

It  must  always  be  remembered  that  the  urine  is  very  susceptible 
to  contamination,  which  may  be  brought  about  either  wilfully  or 
by  accident,  and  that  foreign  bodies  of  all  kinds  may  be  present 
in  it — pus  from  the  vaginal  secretion,  bits  of  Hnt  from  the  clothing, 

or  particles  of  many  kinds 
derived  from  the  dust  and 
the  air;  they  may  also  have 
been  present  in  the  vessel  in 
which  the  specimen  was  re- 
ceived. 

The  microscopic  examijia- 
tion  of  the  urine  must  be  con- 
sidered along  with,  and  not 
aside  from,  the  general  clinical 
manifestations  of  the  case.  It 
must  never  be  lost  sight  of  that 
microscopic  diagnosis,  just  as 
all  other  forms  of  diagnosis,  is 
open  to  error,  and  this  is  par- 
ticularly likely  to  occur  when  conclusions  too  sweeping  are 
attempted  from  mere  microscopic  examination. 


Fig.  53.— Red  blood-corpuscles  in  urine  (Jakob). 

The  crenation  shown  by  many  of  these  cells  is 

quite  characteristic. 


Organized  Deposits 

Red  blood-corpuscles  are  found  in  the  urine  whenever  hemor- 
rhage from  any  cause  is  taking  place  from  any  portion  of  the  uri- 
nary tract.  The  source  of  the  blood  can  be  traced  quite  accurately, 
as  a  rule,  from  the  clinical  history  or  manifestations,  by  the 
presence  of  other  tissue,  as  bits  of  papillomatous  tumors  or  ne- 
crotic tubercles  in  the  urine,  which  may,  from  their  association, 


MICROSCOPIC    EXAMINATION    OV'   THE    URINE 


indicate  the  probable  nature  and  source  of  the  hemorrhage.  The 
quantity  of  blood  present  is,  of  course,  a  matter  of  considerable 
importance;  when  bright  red  and  fresh  in  color,  it  is,  for  example, 
more  likely  to  have  originated  from  the  urethra  than  from  the  upper 
tract. 

Leukocytes  or  pus-cells,  when  they  appear  in  the  urine,  are  indi- 
cative of  inflammatory  or  suppurative  disease.  As  a  rule,  they 
are  accompanied  by  the  discharge  of  bits  of  tissue,  such  as  flakes  of 
epithelial  cells  or  necrotic  connective  tissue  which  may,  in  a  certain 
number  of  cases,  indicate  their  probable  origin.  When  associated 
with  crystals,  they  may  point  to  the  possibility  of  calculus. 

Mucus  in  considerable  amounts  is  often  found  in  the  urine  under 
normal  conditions,  particularly  when  the  secretion  of  the  seminal 
vesicles  or  prostate  gland  is 
present  in  large  quantity.  The 
presence  of  numerous  shreds  of 
mucus  in  the  urine  of  the  male 
is  strongly  indicative  of  an  ex- 
isting prostatitis.  Mucus  in 
large  quantities  is  also  gener- 
ally found  in  cases  of  pelvic 
stone,  and  is  then  often  mixed 
with  more  or  less  pus. 

Epithelium. — Much  has  been 
written  about  the  diagnostic 
possibilities  of  microscopic  ex- 
amination of  the  urine  from 
the  character  of  the  epithelial 
cells  found.     A  wide  diversity 

of  opinion  exists  as  to  the  value  of  this  procedure,  and  it  is  note- 
worthy that  those  who  are  least  familiar  with  the  normal  histology 
of  the  mucosa  of  the  genito-urinary  tract  are  the  firmest  believers  in 
its  diagnostic  importance.  It  should  never  be  forgotten  that  the 
pelves  of  the  kidney,  ureter,  bladder,  and  prostatic  urethra  are  hned 
by  a  type  of  epithelium  that  is  absolutely  identical  in  all.  A 
differentiation,  even  between  masses  of  cells  from  these  localities,  is 
therefore  impossible  from  the  microscopic  findings  alone,  and  the 
clinician  must  form  his  decision  as  to  the  origin  of  the  cells  largely 
from  other  manifestations.     Sometimes  when  cells  occur  in  masses 


Fig.  54. — Squamous  epithelium  from  uiethra 
and  bladder  (Jakob). 
The  superficial  layers  of  the  bladder  con- 
tain large  squamous  epithelial  cells  (a),  the 
deeper  laj-er  club-shaped  cells  with  tenuous 
extremities. 


122 


EXAMINATION    OF   URINE)    AND   URETHRAL   EXUDATE 


those  desquamated  from  the  mucosa  of  the  external  genitals  can 
be  distinguished  by  their  more  squamous  character  from  the 
typical  "transitional"  cells  seen  in  the  epithelium  from  the  mucosa 

of  the  urinary  tract  proper. 
Cells  from  the  renal  tubules 
may  also  occasionally  be  differ- 
entiated from  those  of  the 
lower  layers  of  the  transitional 
epithelium  mainly  by  the  par- 
ench^^matous  character  of  the 
renal  cells.  A  diagnosis  should 
never  be  based  on  an  exam- 
ination of  isolated  cells. 

Fragments  of  tumors  are  oc- 
casionally found  in  the  urine, 
and  they  may  be  of  sufficient 
size  to  make  a  probable  diagno- 
sis possible.     This  should,  however,  be  made  very  cautiously,  unless 
the  fragments  are  sufficiently  large  to  permit  of  proper  orientation 


Fig.  SS- — Renal  epithelium  (Jakob). 


' 

^^ 

'  1 

—^■-^  . 

•  //i  .J 

n 

1 

W^ 

....  ,.^ 

^ 

- 

J 

1  i    ■  '■■ 
\\  \ 

1         \ 

1          \ 

i 
i' . 

"  N  . 

Fig. 56. —  Urinary  tube-casts  (Jakob).  In  the  upper  portion  of  the  figure  are  shown  cylin- 
droids  (a),  which  are  without  significance.  Below  are  hyaline  tube-casts  (6),  which  occur  in 
conjunction  with  all  diseases  of  the  kidney  (inflammation,  stasis,  irritation  by  toxins)  in  the 
form  of  narrow  or  broad  cylinders.  They  occur  as  the  result  of  a  form  of  exudation  into  the 
uriniferous  tubules.  They  are  frequently  the  seat  of  white  blood-corpuscles  (c)  or  of  renal 
epithelium  {d).     The  latter  relation  is  significant  of  profound  disturbance. 

and  sectioning.  Tubercular  or  gummatous  involvement  of  the 
urinary  tract  may  also  occasionally  be  diagnosed  from  necrotic 
masses  of  tissue  in  the  urine. 


MICROSCOPIC   EXAMINATION   OF   THE   URINE 


123 


Fig.  57. — Coarsely   and    finely   granular   tube- 
casts  (Jakob). 


Spermatozoa  or  the  secretion  from  the  seminal  vesicles,  pros- 
tate, or  other  sexual  glands  may  occasionally  be  found  in  the 
urine.  Their  value  in  diagnosis  is  dependent  on  the  constancy 
of  their  appearance,  and  they  can  be  considered  as  a  determining 
factor  only  after  a  careful 
history  of  the  case  has  been 
taken  and  their  probable  rela- 
tionship or  irrelavence  to  dis- 
ease suggested. 

CyUndroids  are  long,  usually 
more  or  less  convoluted,  shreds 
of  mucus,  which  are  to  be  dis- 
tinguished from  true  hyaline 
casts  by  the  filamentous  ends 
of  the  former.  Their  manner 
of  formation  is  uncertain. 

Casts. — The  occurrence  of 
casts  in  the  urine  is,  as  a  rule, 
considered  of  too  much  importance  in  diagnosis,  and  is  really  valu- 
able only  when  considered  in  conjunction  with  the  entire  aspect  of 
the  case.     They  are,  however,  a  more  certain  index  of  renal  disease 

than  the  presence  of  albumin. 
Thus  they  may  appear  in 
considerable  numbers  in  the 
beginning  of  active  diuresis, 
without  indicating  actual  dis- 
ease of  the  kidney.  On  the 
other  hand,  they  are  sometimes 
entirely  absent  in  serious  cases 
of  nephritis.  When  they  are 
present  constantly  in  numbers 
they  may  be  looked  upon  as 
probably  the  one  most  absolute 
diagnostic  symptom  of  nephri- 
tic disease,  although  this  dis- 
ease may  be  confined  exclusively  to  one  kidney  or  even  to  a 
portion  of  one  or  both  organs.  The  character  of  the  casts  is  of 
much  importance  in  this  relation. 


Fig.  58. — Waxy  tube-casts  (Jakob). 


124  EXAMINATION   OF   URINE    AND   URETHRAL   EXUDATE 


Fig-  59- — Blood-casts  (Jakob). 


Hyaline  casts  are  clear,  transparent,  narrow,  thovfgh  sometimes 
broad,  cylindric  bodies.  They  are,  at  times,  found  in  practically 
all  specimens  of  urine.     When  constantly  present  in  considerable 

number,  they  are  strongly  in- 
dicative of  nephritis,  partic- 
ularly of  the  diffuse  interstitial 
variety.  Their  size  depends 
on  the  caliber  of  the  tube  in 
which  they  are  formed. 

Granular  casts  occur  more 
constantly  associated  with  dis- 
ease of  the  renal  parenchyma. 
Their  granular  character  is 
probably  the  result  of  the  de- 
tritus following  parenchyma- 
tous degeneration  and  disinte- 
gration of  the  renal  epithe- 
lium. They  are  classed  as  coarsely  or  finely  granular  or  accord- 
ing to  their  size. 

Epithelial  casts  appear  in  the  urine  when  desquamation  of  the 
tubular  epithelium  is  taking  place.     They  consist  of  a  hyaline  cast 
to   which   epithelial   cells   are 
clinging    in    greater    or    less 
number. 

Amyloid  or  waxy  casts,  which 
respond  to  microchemic  reac- 
tions for  amyloid,  are  found 
chiefly,  though  perhaps  not 
exclusively,  as  the  result  of 
amyloid  degeneration  of  the 
kidney. 

Pus-  and  blood-casts  are  de- 
fined by  their  names,  and  are 
diagnostic  of  renal  suppuration 
and  hemorrhage  respectively. 

Fatty  casts  are  seen  where  fatty  degeneration  of  marked  degree 
is  present,  or  in  chyluria. 


Fig.  60. — Fatty  casts  (Jakob). 


MICROSCOPIC    IJXAMINATION   OF   THE   URIN© 


125 


Fig.  61. — Uric  acid  crystals  (Jakob). 


Crystalline  Deposits  in  the  Urine 
It  must  be  remembered  primarily  that  the  occurrence  of  crvs- 
talHne  deposits  in  a  specimen  presented  for  examination  is  by  no 
means  an  unfaiHng  indication 
that  those  substances  are  pres- 
ent in  abnormal  quantities,  for 
unless  they  are  passed  as 
strictly  abnormal  substances, 
they  may  be  precipitated  as  a 
result  of  the  chemic  character- 
istics of  the  urine,  rather  than 
as  an  evidence  of  oversatura- 
tion  or  from  changes  which 
have  taken  place  in  the  urine 
after  it  has  been  voided.  These 
substances  are,  for  convenience 
of  description,  best  considered 

under  two  headings — those  found  in  acid  and  those  present  in  alka- 
line urines. 

Substances  Found  in  Acid  Urine. — One  of  the  most  frequent  pre- 
cipitates found  in  acid  urine,  particularly  that  of  a  highly  acid  char- 
acter, is  the  familiar  reddish  or 
bn'ck-colored  deposit  of  uric 
acid  or  of  the  urates  of  sodium 
or  potassium.  Although  their 
occurrence  may  not  be  strictly 
pathologic,  they  indicate  a  ten- 
dency toward  the  formation  of 
uric-acid  calculi,  particularly 
when  associated  with  certain 
colloidal  substances.  The  va- 
riety of  crystalline  forms  as- 
sumed by  uric  acid  and  its  salts 
in  the  urinary  deposit  is  large, 
and  it  must  be  remembered 
that  these  crystals  are  not  always  of  the  characteristic  reddish 
color,      (For  a  detailed  description  of  the  forms  that  uric  acid  may 


Fig.  62. — Sodium  urate  (Jalcob). 


126 


EXAMINATION    OF   URINE   AND   URETHRAL   EXUDATE 


Fig.  63. — Calcium-oxalate  crystals  (Jakob), 


take  on,  the  reader  is  referred  to  the  special  works  on  urinary 
diagnosis.) 

Calcium-oxalate  crystals  are  one  of  the  most  frequent  forms  of 

urinary  sediment.  They  are 
occasionally  seen  in  urines  that 
have  undergone  slight  alkaline 
fermentation,  although  usu- 
ally they  occur  only  in  acid 
urine.  Macroscopically,  cal- 
cium-oxalate appears  as  a 
hazy  mucoid  cloud  settling 
slightly  at  the  bottom  of  the 
receptacle.  It  occurs  as  the 
result  of  certain  dietetic  dis- 
orders or  after  the  ingestion 
of  certain  foods,  as  rhubarb  or 
asparagus,  rich  in  oxalates. 
It  is  also  quite  constantly  found  associated  with  some  forms  of 
nervous  disease,  as  neurasthenia,  but  the  condition  is  chiefly 
important  as  pointing  to  the  possibility  of  renal  or  cystic  cal- 
culus formation. 

Cystin  is  a  chemic  substance  rarely  appearing  in  the  urine. 
It  occurs  in  the  form  of  highly 
refractive  six-sided  plates.  It 
is  a  product  of  proteid  metab- 
olism, and  beyond  the  fact  that 
it  may  form  the  nucleus  of  a 
calculus,  is  of  slight  clinical 
significance. 

Leucin  2in6.  tyrosin  are  crys- 
talline substances  the  ultimate 
recognition  of  which  must 
depend  on  chemic  reactions. 
They  occur  in  the  urine  as  the 
result  of  serious  metabolic  dis- 
turbances of  the  liver,  partic- 
ularly in  acute  yellow  atrophy. 

Large  quantities  of  amorphous  phosphates  may  occur  in  either 
acid  or  alkahne  urine.     They  are  found  most  abundantly  in  febrile 


Fig.  64. — Tyrosin  crystals  (Jakob). 


MICROSCOPIC   EXAMINATION   OF   THE   URINE 


127 


Fig.  65. — Leucin  (Jakob). 


urine,  after  pronounced  tissue  destruction,  when  the  phosphates  of 
the  urine  are  greatly  increased  as  a  result  of  the  diet,  and  occa- 
sionally after  severe  mental  or 
nervous  disturbances. 

Substances  Found  in  Alkaline 
Urine. — The  most  frequent 
crystalUne  body  that  appears 
in  alkahne  urine  is  the  familiar 
cofi&n-lid-shaped  crystal  of 
ammonio  -  magnesium  phos- 
phate. It  may  occur  whenever 
alkaline  fermentation  is  tak- 
ing place,  and  though  the  crys- 
tals are  commonly  of  the  shape 
just  mentioned,  other  forms 
are  occasionally  seen. 

Calcium  carbonate  appears  at  times  in  the  urine  as  large  globular 
masses.    Its  clinical  significance  has  not  been  definitely  determined. 

Ammonium  urate  occurs  in  alkahne  urine  under  conditions  simi- 
lar to  those  under  which  the  other  salts  of  uric  acid  may  be  found, 
and  not  infrequently  represents  acid  salts  of  uric  acid  in  urines 

that  have  undergone  alkaline 
fermentation. 

Bacteria  in  the  Urine 
The  most  important  of  the 
bacteria  commonly  found  in 
the  urine  are  those  that  are 
concerned  in  the  various  in- 
fectious processes  attacking 
the  genito-urinary  organs. 

The  gonococcus  is,  of  course, 
found  in  cases  of  genito-uri- 
nary gonorrhea,  its  recogni- 
tion, both  clinically  and  micro- 
scopically, usually  being  easy.  Streptococci,  staphylococci,  and 
green-pus  bacilli  occur  more  or  less  frequently  as  primarv  infecting 
organisms,  or,  more  commonly,  in  the  course  of  mixed  infections, 
as  in  cases  of  gonorrheal  or  tubercular  disease.     The  proteus  and 


Fig.  66. — Crystals  of  cystin  (Jakob). 


128 


EXAMINATION    OF   URINE    AND   URETHRAL   EXUDATE 


colon  bacilli  are  very  frequently  found  in  the  more  chronic  inflam- 
matory diseases  of  the  genito-urinary  tract. 

As  will  be  more  fully  discussed  under  the  proper  heading,  the 
recognition  of  the  tubercle  bacillus  in  the  urine  is  often  a  matter 
of  considerable  difficulty.  Except  when  it  occurs  in  large  numbers, 
mere  morphologic  and  microchemic  reactions  are  neither  positively 
nor  negatively  satisfactory,  the  findings  in  many  cases  requiring 
substantiation  by  animal  inoculation,  though  by  the  use  of  the 
antiformin  method  much  more  certain  and  positive  results  are 
now  possible  (see  p.  241).  The  recognition  of  the  tubercle  bacil- 
lus is  particularly  dif&cult  because  of  its  close  similarity,  in 
microchemic  reactions,  to  certain  forms  of  the  smegma  and 
timothy  hay  bacilli,  which  very  commonly  infest  the  genito- 
urinary secretion. 

Actinomyces  fungi  are  occa- 
sionally found  in  the  urine,  an 
indication,  of  course,  that  gen- 
ito-urinary actinomycosis  ex- 
ists. 

Echinococcus  -  hooklets  are 
found  in  some  cases  of  echino- 
coccus cysts,  and  the  embryos 
of  the  filaria  sanguinis  hominis 
are  occasionally  found  in  cases 
of  chyluria  due  to  filarial  in- 
fection. 

The  trichomonas  vaginalis 
and  cercomonas  intestinalis  are  occasionally  seen,  usually 
associated  with  chronic  inflammatory  diseases. 

Still  other  micro-organisms  appear  in  the  urine  from  time  to 
time  in  specific  types  of  disease  or  accidental  infections  of  the 
genito-urinary  tract. 


Fig.  67. — Ammoniomagnesium  phosphate  crys 
tals  (Jakob). 


EXAMINATION  OF  THE  URETHRAL  EXUDATE 

Whenever  possible,  the  physician  should  himself  collect  the 
specimen  for  examination,  for  at  this  time  the  gross  appearance, 
exact  point  of  origin,  odor,  reaction,  and  the  amount  of  discharge 
can  best  be  ascertained.  Oftentimes  a  brief  history  of  the  case  will 
at  once  suggest  the  portion  of  the  urinary  tract  that  is  the  source 


EXAMINATION  OF  THE  URETHRAL  EXUDATE        1 29 

of  the  discharge;  when  the  amount  obtained  for  examination  is 
small,  the  history  will  likewise  determine  the  methods  best  calcu- 
lated to  demonstrate  the  points  in  question  and  no  waste  of 
material  need  follow. 

Whenever  the  amount  and  character  of  the  material  permit,  an 
examination  should  be  made  of  the  fresh  specimen;  this  is  done  by 
placing  a  drop  on  a  clean  slide,  and  allowing  a  well-cleansed  cover- 
glass  to  fall  upon  it,  thus  flattening  it  out  sufficiently  for  micro- 
scopic study.  Examination  with  a  dry  lens,  a  No.  6  or  7  Leitz,  or 
DD  Zeiss,  will  usually  reveal  the  nature  of  the  discharge. 

In  order  to  properly  study  a  specimen  it  is  necessary,  in  almost 
all  cases,  to  eventually  resort  to  staining  methods.  As  a  prelimin- 
ary step  in  the  preparation  of  such  a  specimen  it  is  customary  to 
spread  the  material  over  the  surface  of  a  clean  slide.  This  is  best 
effected  by  collecting  the  exudate  in  a  drop  near  the  end  of  a  well- 
cleaned  slide;  a  second  slide  is  then  approximated  obliquely  to 
this  drop,  causing  it  to  spread  along  the  whole  line  of  contact;  the 
upper  slide  is  then  drawn  steadily  across  the  first  slide,  spreading 
the  exudate  as  a  thin  film  over  the  greater  part  of  the  surface  of  the 
first  slide.  This  process  is  the  same  as  that  usually  employed  in  the 
making  of  a  blood-slide.  The  specimen  should  then  be  allowed  to 
dry  in  the  air.  The  subsequent  method  of  fixation  to  be  employed  is 
dependent  entirely  on  the  nature  of  the  material,  as  determined 
from  the  gross  and  from  the  microscopic  examination  of  the  fresh  spe- 
cimen, and  on  the  facts  likely  to  be  derived  from  microscopic  study. 

Purulent  Discharges. — Acute  purulent  discharges  are,  as  a  rule, 
opaque,  thick,  and  creamy.  They  spread  easily  and  regularly 
under  the  pressure  of  the  cover-glass,  and  are  not  uncommonlv 
tinged  with  blood.  The  color  is  dependent  largely  on  the  char- 
acter of  the  organisms  present;  thus  when  the  pus  is  due  to  an 
infection  with  the  staphylococcus  pyogenes  aureus,  it  is  yellow 
or  golden  in  color;  when  due  to  a  white  staphylococcus,  it  is 
light  gray  or  white;  when  the  green-pus  bacillus  is  present,  it  is 
greenish  in  color.  When  large  portions  of  the  exudate  are  made 
up  of  mucus,  as  from  uterine  or  prostatic  discharges,  this  fact  is 
at  once  manifest  from  the  tenacious  nature  of  the  discharge  and 
the  difficulty  with  which  it  is  spread  on  the  slide. 

In  examining  purulent  discharges,  the  slide  is  best  fixed  by  heat- 
ing it  on  the  copper  plate  or  by  holding  it  above  the  Bunsen  or 
9 


130  EXAMINATION    OF   URINE   AND   URETHRAL    EXUDATE 

alcohol-lamp  flame  until  the  surface  becomes  too  hot  to  be  held 
comfortably,  but  not  until  the  upper  or  prepared  side  becomes 
browned,  or  the  specimen  is  ruined.  SHdes  may  also  be  fixed  by 
immersing  the  well-dried  sHde  in  a  solution  of  chemically  pure 
methyl- alcohol  for  from  two  to  ten  seconds ;  as  a  rule,  however, 
heat  fixation  is  more  generally  satisfactory. 

After  the  slide  has  been  fixed,  the  examiner  selects  the  most 
suitable  method  of  staining  according  to  the  points  that  are  to  be 
elucidated  by  the  examination. 

When  but  a  general  knowledge  of  the  discharge  and  of  the 
organisms  present  is  desired,  the  best  method,  perhaps,  is  to 
stain  the  specimen  with  the  familiar  alkaline  solution  of  methylene- 
blue  known  as  Lofiler's  methylene-blue.  The  fixed  slide  may  be 
immersed  in  a  jar  filled  with  this  stain,  or  the  stain  may  be  dropped 
on  the  slide,  the  latter  being  gently  heated  over  the  flame  to  has- 
ten the  staining  process.  By  this  means  bacteria  and  all  chro- 
matic elements  are  stained  a  deep  blue,  the  nuclei  of  epithelial 
and  connective-tissue  cells  being  similarly  stained;  the  cyto- 
plasm is  stained  a  lighter  shade.  If  the  specimen  is  stained  too 
deeply,  the  excess  of  color  may  be  removed  by  immersing  in  70 
per  cent,  alcohol  for  a  few  seconds.  If  desired,  the  slide  may 
similarly  be  stained  by  one  of  the  aqueous  forms  of  polychrome 
methylene-blue,  which  gives  a  much  wider  color  scheme  to  the 
elements  of  the  specimen;  in  order  to  use  this  dye  satisfactorily, 
however,  the  specimen  must  first  have  been  fixed  with  methyl- 
alcohol.  After  the  staining  process  has  been  completed,  the 
slide  may  be  dried  rapidly  by  waving  it  to  and  fro  in  the  air  after 
first  draining  off  the  water  in  which  it  was  washed,  or  it  may  be 
dried  between  two  sheets  of  filter-paper,  and  placed  for  a  minute 
in  the  hot  oven,  or  it  may  be  held  above  the  Bunsen  flame  until 
it  is  entirely  dry.  The  slide  may  then  be  examined  with  the 
oil  lens,  by  simply  allowing  a  drop  of  cedar  oil  to  fall  on  the  speci- 
men where  the  lens  is  to  be  approximated.  When  it  is  desired  to 
preserve  the  specimen  for  future  reference  or  study,  it  is  best,  after 
drying,  to  cover  it  with  Canada  balsam  or  damar  and  place  it 
under  a  cover-glass,  after  which  the  examination  may  be  made. 
Specimens  prepared  in  this  manner  are  practically  indestructible, 
whereas  when  no  cover-glass  is  used,  they  soon  begin  to  fade. 

When  the  presence  of  tubercle  bacilli  is  suspected,  the  slide 


EXAMINATION   OF    THE   URETHRAL    EXUDATE  13I 

should  first  be  stained  with  the  usual  carbol-fuchsin,  which  should 
be  rendered  more  intense  by  the  addition  of  heat  until  a  vapor 
arises  from  the  dye.  The  stain  is  then  to  be  removed  by  first 
washing  in  water  and  then  in  2  per  cent,  hydrochloric  acid  in  a 
solution  of  70  per  cent,  alcohol  until  the  specimen  becomes  gray  in 
color.  The  acid  alcohol  is  next  removed  by  washing  in  water,  and 
the  specimen  may  be  counterstained  by  methylene-blue.  If  the 
tubercle,  leprosy,  or  certain  other  special  organisms  are  present, 
they  appear  as  bright-red  bodies,  all  the  other  tissues  and  bacteria 
being  stained  blue.  "When  much  pus,  mucus,  or  other  contaminat- 
ing material  is  present  in  the  sediment,  it  is  best  to  add  antifor- 
min,  so  that  it  is  digested  away,  leaving  the  tubercle  bacilli  much 
easier  to  detect.  One  must  be  particularly  careful  in  drawing 
conclusions  from  this  purely  morphologic  method.  Very  commonly 
the  smegma  bacillus,  which  is  found  abundantly  about  the  genitals, 
is  mistaken  for  the  tubercle  bacillus.  Ordinarily,  the  smegma 
bacillus  is  decolorized  by  acid  alcohol,  but  occasionally  this  is  not 
the  case;  in  order,  therefore,  to  obtain  absolute  results  in  sus- 
pected tubercular  disease  the  abdominal  cavity  of  a  guinea-pig 
should  be  inoculated  wdth  the  exudate,  and  after  a  period  of  six 
weeks  the  animal  should  be  killed.  If  the  suspected  material 
contained  living  tubercle  bacilli,  the  peritoneum,  liver,  and  spleen 
will  be  found  studded  with  tubercles.  This  carbol-fuchsin  staining 
method  acts  very  satisfactorily  not  alone  for  the  demonstration  of 
the  tubercle  bacillus,  but  it  also  serves  to  demonstrate  clearly 
the  general  character  and  bacterial  content  of  simple  exudates  and 
may  be  well  employed  as  a  routine  method. 

Another  important  method  of  staining  is  that  known  as  Gram's 
method;  by  means  of  this  it  is  possible  to  differentiate  bacteria 
that  do  not  decolorize  from  those  that  do.  The  method  is  valua- 
ble chiefly  in  genito-urinary  work  for  eliminating  or  identifying 
the  gonococcus,  which  might  otherwise  be.  mistaken  for  the  dip- 
lococcus  catarrhalis  or,  in  some  cases,  for  the  pneumococcus. 

After  heat  fixation  the  specimen  is  to  be  stained  with  aniUn 
water  gentian- violet  solution,  and  the  excess  of  stain  removed  by 
rinsing  in  water,  after  which  it  is  transferred  to  Gram's  solution 
(iodin,  I  gm. ;  .potassium  iodid,  2  gm.;  water,  300  c.c).  The 
specimen  is  allowed  to  remain  in  this  solution  for  from  one  to  two 
minutes,  when  it  is  removed  and  rinsed  in  80  per  cent,  alcohol 


132    KXAMINATION  OF  URINE  AND  URETHRAL  EXUDATE 

until  no  trace  of  the  violet  color  remains.  For  this  purpose  it 
may  be  necessary  to  return  the  specimen  for  a  few  minutes  to 
the  iodin  solution.  The  preparation  may  then  be  counterstained, 
if  desired,  with  Bismarck-brown,  eosin,  or  some  other  contrasting 
dye.  By  this  method  "Gram-positive  organisms,"  such  as  the 
ordinary  cocci,  retain  the  deep  violet  color,  and  "Gram-negative 
organisms,"  such  as  the  gonococcus,  take  up  the  contrasting  dye. 
Since,  in  this  method,  man}-  technical  errors  are  likely  to  occur, 
it  is  well  first  to  place  on  the  specimen,  side  by  side  with  the  sus- 
pected discharge,  a  pure  culture  of  some  well-known  Gram-posi- 
tive organism,  such  as  the  staphylococcus;  by  means  of  this 
control  test  it  can  be  learned  to  a  certainty  whether  or  not  the 
process  has  been  managed  correctly. 

Simple  Urethritis. — The  exudate  in  simple  or  nonspecific  ure- 
thritis often  so  closely  resembles  that  seen  in  gonorrhea  that  it 
can  be  distinguished  only  by  making  a  bacterial  examination  of 
the  discharge.  The  amount  of  pus  found  in  the  specimen  neces- 
sarily varies — when  the  infecting  organisms  are  of  an  actively  pyo- 
genic character,  the  number  of  pus-cells  is  large;  when,  on  the  con- 
trary, the  organisms  depart  from  this  type,  as,  for  example,  in  the 
case  of  the  streptococcus,  the  specimen  will  be  found  to  be  made 
up  largely  of  mucus  and  serum  in  which  pus-cells  naturally  min- 
gle, but  are  less  abundant.  As  a  rule,  the  pus-cells  found  are  of 
the  polynuclear  neutrophilic  variety,  but  small  lymphocytes  may 
be  found,  particularly  in  exudates  of  long  standing,  and  some- 
times in  preponderating  numbers.  Eosinophilic  pus-cells  are 
occasionally  seen,  being  not  uncommonly  present  in  the  exudate 
of  specific  urethritis. 

Epithelial  cells  are  found  in  the  discharge  in  greater  or  less 
number,  being  much  more  abundant  in  the  more  acute  discharges. 
To  a  certain  limited  degree  the  character  of  the  cells  will  point  to 
the  seat  of  greatest  inflammation — thus,  for  example,  when  the 
process  is  limited  chiefly  to  the  fossa  navicularis,  squamous  cells 
predominate ;  when  to  the  penile  urethra,  columnar  cells.  When 
the  process  has  been  of  long  standing,  as  a  rule  epithelial  cells, 
if  found  at  all,  are  present  in  but  very  small  numbers. 

Red  blood-cells  may  be  found  in  small  numbers  in  nearly  all 
discharges,  but  as  a  matter  of  course  they  are  most  common  in 
acute  and  active  processes. 


EXAMINATION  OF  THE  URETHRAL  EXUDATE        1 33 

One  of  the  most  important  points  to  be  learned  by  the  micro- 
scopic examination  of  the  urethral  discharge  is  that  of  ascertaining 
the  bacterial  content.  In  most  cases  staphylococci  or  strepto- 
cocci will  be  found  to  be  present;  if  the  latter,  the  disease  will 
generally  be  found  to  be  an  active  one.  Occasionally  the  diplo- 
coccus  catarrhalis  is  present.  This  organism  is  distinguished 
with  considerable  difficulty  from  the  gonococcus,  and  its  recogni- 
tion is  often  of  great  importance  in  questionable  infections. 
It  may  be  recognized  chiefly  by  its  great  variability  in  size,  its 
diminished  tendency  toward  a  diplococcus  arrangement,  and  its 
less  flattened  surfaces  where  the  pairs  are  opposed.  It  may  be 
both  intra-  and  extra-cellular.  Further,  it  is  not  decolorized  by 
Gram's  method,  and  in  doubtful  cases  it  may  readily  be  differen- 
tiated by  cultural  methods,  for  the  diplococcus  catarrhalis  grows 
readily  on  ordinary  media,  whereas  the  gonococcus  does  not. 

When  the  discharge  is  of  long  standing,  as  a  rule,  the  bac- 
terial content  will  be  found  mixed,  bacilli  of  various  forms  being 
present.  The  colon  and  proteus  groups  are  particularly  likely 
to  be  seen  in  these  exudates,  and  the  discharge  is  generally  of  a 
highly  mucoid  or  serous  character. 

When  the  preparations  for  examination  are  made  as  soon  as 
the  discharge  is  removed  from  the  urethra,  we  are  justified  in 
attributing  an  etiologic  significance  to  the  bacteria  demonstrated 
by  an  examination  of  the  smear;  in  long-standing  infec- 
tions, however,  it  must  be  remembered  that  extensive  mixing 
with  contaminating,  and  very  likely  unimportant,  organisms 
takes  place.  Cultures  are  important  only  when  some  special 
organism  is  sought  or  desired  for  purposes  of  identification,  but 
they  are  often  very  misleading,  inasmuch  as  the  organisms  that 
grow  most  actively  on  artificial  media  may  have  the  least 
significance  in  the  causation  of  the  discharge. 

The  student  should  not  be  content  with  a  single  examination, 
particularly  in  long-standing  urethritis,  and  it  is  often  necessary 
to  make  several  investigations  under  varying  conditions  before 
the  true  nature  of  the  discharge  will  become  evident.  This  is 
particularly  true  when  gonorrhea  is  to  be  excluded,  a  matter  to 
be  discussed  more  fully  further  on. 

Gonorrheal    Urethritis. — The    discharge    in    acute    gonorrheal 


134  EXAMINATION    OF    URINE   AND   URETHRAL    EXUDATE 


urethritis  is  typically  purulent  in  character.  Pus-cells  are  very 
abundant;  as  a  rule,  they  are  of  the  polynuclear  neutrophilic 
variety,  but  in  some  cases  eosinophilic  pus-cells  appear  to  pre- 
dominate. Epithelial  cells  are  present  in  large  numbers,  particu- 
larly after  the  exudate  has  become  well  estabHshed,  for  at  first 
the  discharge  appears  only  as  a  mucoid  secretion  in  which  a  few 
pus-cells  and  desquamated  epithelial  cells  are  found.  The  cells 
seen  in  the  early  stages  are  chiefly  of  the  squamous  variety,  and 
their  origin  is  unquestionably  in  the  fossa  navicularis;  later,  as 
the  penile  portion  of  the  urethra  and  the  glands  of  Littre  become 

involved,  they  become  more 
rare  and  are  chiefly  of  the 
columnar  type.  Both  pus- 
cells  and  epithelial  cells  often 
show  marked  hydropic  de- 
generation, and  unless  the 
specimen  is  prepared  soon 
after  the  discharge  is  col- 
lected, such  extensive  necro- 
sis may  take  place  in  all  the 
structures  found  as  greatly 
to  lessen  the  accuracy  and 
value  of  the  examination. 
Mucus  is  present  in  moder- 
ate amounts;  in  the  early 
stages,  as  has  been  men- 
tioned, it  may  predominate,  but  in  most  cases  the  purulent 
elements  are  so  abundant  that  the  mucus  is  not  evident.  Blood- 
cells  are  almost  constantly  present  in  acute  cases,  especially 
when  extensive  infiltration  of  the  urethral  walls  or  of  the  urethral 
glands  is  taking  place.  When  chordee  is  present,  or  when  undue 
mechanic  traumatism  is  inflicted,  the  amount  of  blood  is  found 
to  be 'increased. 

The  detection  of  the  gonococcus  is,  of  course,  the  most  impor- 
tant finding  to  be  eUcited  from  a  microscopic  examination  of  the 
exudate.  As  a  rule,  gonococci  appear  in  large  numbers  even  in 
specimens  collected  in  the  very  early  stages,  before  the  discharge 
has  become  markedly  purulent;   it  is,  therefore,  possible  to  diag- 


Fig.  68. — Gonorrheal  exudate  from  a  case 
of  eight  days'  standing,  showing  presence  of 
gonococci  in  pus-cells.  Objective  xj  oil  im- 
mersion, ocular  No.  4. 


EXAMINATION    OF   THE   URETHRAL   EXUDATE  1 35 

nose  a  gonorrheal  urethritis  before  important  clinical  symptoms 
develop,  by  the  detection  of  gonococci.  In  these  very  early  cases 
the  gonococci  are  found,  for  the  greater  part,  free  in  the  mucus 
that  is  present  in  the  fossa  navicularis,  although  they  are  gener- 
ally found  also  in  the  C3rtoplasm  of  such  pus-cells  as  may  be  present. 
As  the  exudate  becomes  more  abundant  and  typically  purulent, 
gonococci  are  found  in  very  large  numbers  in  both  the  mucous  and 
the  serous  elements  of  the  discharge  and  in  the  cytoplasm  of  the  pus- 
cells,  where  they  may  appear  in  such  enormous  numbers  as  com- 
pletely to  obscure  the  nucleus  and  granulation  of  the  cells.  The 
morphology  of  the  gonococcus  is,  fortunately,  in  itself  sufficiently 
characteristic  to  permit  of  its  recognition,  in  most  cases,  without 
special  technical  difficulties.  This  does  not  hold,  as  we  shall  see 
in  the  examination  of  the  exudate  in  chronic  gonorrheal  urethritis. 

The  gonococci  occur  in  the  form  of  biscuit-shaped  organisms. 
They  are  commonly  found  in  pairs,  the  apposed  portions  of  which 
show  characteristic  flattening.  As  a  result  of  division,  groups  of 
four,  eight,  or  more  are  seen,  and  occasionally  masses  are  found 
that  render  recognition  somewhat  more  difficult.  As  a  rule,  the 
"coffee-bean"  shape  is  well  preserved,  and,  even  in  atypical  cases, 
the  diplococcoid  arrangement  is  evident. 

In  the  early  stages  of  most  cases  of  acute  gonorrhea,  bacteria 
other  than  the  gonococcus  are  absent  or  scanty,  and  even  in 
those  cases  of  some  weeks'  standing  the  number  of  gonococci  so 
overwhelmingly  exceeds  that  of  any  contaminating  organism 
that  little  doubt  as  to  the  etiologic  relationship  to  the  clinical 
signs  and  as  to  the  specific  nature  of  the  organism  can  exist. 
When,  however,  the  original  infection  has  been  a  highly  mixed 
one,  as  when  filthy  conditions  have  been  associated  with  the 
primary  gonorrhea,  other  organisms  may  be  present  in  such  num- 
bers as  to  render  the  making  of  a  purely  morphologic  diagnosis 
somewhat  difficult,  besides  altering  the  clinical  aspects  of  the 
case.  In  these  cases  of  acute  gonorrhea  it  may  become  necessary 
to  employ  more  complicated  differential  methods  for  the  absolute 
identification  of  the  gonococcus;  ordinarily,  however,  specimens 
stained  by  the  methylene-blue  method  give  quite  satisfactory 
results.  Whenever  any  doubt  exists  or  the  disease  must  be 
viewed  from  a  medicolegal  standpoint,  the    specimens  must  be 


136  EXAMINATION    OF    URINE    AND   URETHRAL   EXUDATE 

stained  by  Gram's  method;  when  this  is  done,  the  gonococci  are 
decolorized  and  the  other  infecting  cocci  retain  the  gentian-violet 
color.  This  latter  test,  however,  is  not  absolute,  and  when  medico- 
legal identification  is  demanded,  it  may  be  necessary  to  resort  to 
culture-methods;  these  require  a  considerable  amount  of  techni- 
cal skill,  for  the  gonococcus  grows  sparsely  even  on  the  most 
carefully  prepared  artificial  soil,  and  negative  results,  even  in 
well-identified  cases,  are  more  frequent  than  positive.  When  the 
organisms  grow  on  ordinary  culture-media,  it  may  be  taken  as 
positive  evidence  that  they  are  not  gonococci.  As  has  already 
been  stated,  it  is  rarely  necessary,  for  clinical  purposes,  to  resort 
to  these  methods;  it  is  usually  quite  sufficient  to  employ  the 
ordinary  methods  for  staining,  followed,  if  any  question  arises, 
by  Gram's  method. 

The  exudate  of  chronic  gonorrheal  urethritis  does  not  differ  in 
appearance  from  that  seen  in  simple  chronic  urethritis.  Mixed 
infection  is  the  rule,  and  in  these  long-standing  cases  it  is  often 
imxpossible  to  decide,  from  the  examination  of  specimens,  as  to 
the  relative  etiologic  significance  of  the  bacteria  shown  to  be 
present.  Occasionally  gonococci  may  still  be  found  in  consider- 
able numbers,  and  no  difficulty  may  be  experienced  in  recognizing 
them.  In  other  cases,  where  the  discharge  is  of  a  distinctly  gleety 
character,  the  most  conscientious  search  may  fail  to  reveal  the 
presence  of  a  single  definite  gonococcus.  In  cases  of  this  nature, 
particularly  when  the  subject  contemplates  marriage,  repeated 
examinations  should  be  made;  in  important  cases  it  is  well  to 
excite  a  more  or  less  acute  inflammatory  reaction  in  the  urethra, 
since  by  these  means  the  gonococci  may  occasionally  reappear 
in  recognizable  form  and  numbers.  It  is  to  be  remembered  that 
in  many  of  these  chronic  cases  the  organisms  do  not  present  their 
typical  form.  They  are  less  diplococcoid  in  arrangement,  the 
biscuit  shape  is  less  evident,  and  their  size  is  often  considerably 
reduced.  In  very  many  cases  they  are  entirely  unrecognizable 
morphologically,  although,  when  inoculated  on  a  normal  mucous 
membrane,  they  readily  set  up  a  typical  inflammation.  In  these 
cases,  therefore,  repeated  examinations  should  be  made  and  the 
preparations  gone  over  by  means  of  a  mechanic  stage ;  the  speci- 
mens should  also  be  taken  under  varying  conditions.     Cultural 


EXAMINATION    OF   THE   URETHRAL   EXUDATE  137 

methods  are,  in  the  opinion  of  the  writers,  of  httle  or  no  assistance 
in  these  cases.  In  important  clinical  cases  and  in  those  which 
must  be  considered  socially,  it  is  best  to  consider  the  gonococcus 
as  present  until  absolutely  negative  conclusions  have  shown  it  to 
be  absent.  In  medicolegal  cases,  the  opposite  standpoint  should 
be  taken. 

The  Secretion  in  Prostatitis. — Although  in  by  far  the  larger 
number  of  cases  prostatitis  is  preceded  by  posterior  urethritis, 
which  ordinarily  persists  throughout  the  course  of  the  disease, 
this  is  not  invariably  the  case. 

Acute  prostatitis  is,  as  a  rule,  accompanied  by  acute  urethritis, 
and  when  this  association  occurs,  the  condition  is  readily  recog- 
nized from  the  general  clinical  aspects,  although  the  secretion 
may  present  but  little  that  is  of  diagnostic  importance.  When 
the  prostate  becomes  involved,  shreds  of  mucus  and  mucopus 
formed  in  the  prostatic  acini  and  ducts  generally  appear  in  the 
urine;  these  may,  however,  become  confused  with  similar  bodies 
that  are  not  uncommonly  formed  in  the  ducts  of  the  glands  of 
Littre.  Corpora  amylacea  may  also  appear,  but,  as  previously 
stated,  it  is  most  difficult  definitely  to  determine,  from  the  micro- 
scopic or  gross  examination  of  the  exudate,  whether  or  not  inva- 
sion of  the  prostate  has  taken  place.  When  bacteria  appear  in 
the  shreds  of  mucopus  it  will,  as  a  rule,  be  found  that  these  or- 
ganisms bear  some  etiologic  relationship  to  the  disease. 

In  the  absence  of  urethritis,  evidence  of  the  existence  of  inflam- 
matory disease  of  the  prostate  may  be  secured  by  first  cleansing 
the  urethra  by  urination  or  mechanic  washing,  and  then,  by 
massaging  the  prostate,  forcing  the  secretion  from  its  acini  into 
the  posterior  urethra,  from  which,  by  voiding  a  small  amount  of 
urine,  the  specimen  may  be  secured  for  examination.  Conclu- 
sions must  be  carefully  drawn  from  the  examination  of  specimens 
obtained  in  this  manner,  for  it  must  be  remembered  that  the  pros- 
tatic secretion  so  obtained  normally  contains  elements  that  might 
erroneously  be  regarded  as  indicative  of  inflammatory  disease. 
Thus,  under  normal  conditions,  there  will  be  found  leukocytes  in 
considerable  numbers;  mucus,  largely  in  the  form  of  shreds; 
and  corpora  amylacea,  with  masses  of  isolated  epithelial  cells  of  the 
columnar  variety.     When,  however,  pus-cells  are  found  in  abun- 


138  EXAMINATION    OF   URINE    AND   URETHRAL   EXUDATE 

dance  and  blood  occurs  in  more  than  minute  quantities,  and 
when  bacteria  are  found  to  be  present,  disease  of  greater  or  less 
extent  may  safely  be  said  to  exist.  E^nough  has  already  been 
said  in  regard  to  the  examination  of  the  urethral  exudates  con- 
cerning the  character  of  these  bacteria  and  the  methods  for 
demonstrating  their  presence,  but  mixed  infections  are  not  the 
rule.  The  examination  of  the  prostatic  secretion  is  particularly 
advised  in  cases  of  supposedly  healed  gonorrhea,  for  a  few  infected 
acini  of  the  prostate  gland,  although  quite  sufficient  to  cause  infec- 
tion of  another  individual,  may  exist  indefinitely  without  exciting 
symptoms  that  would  attract  the  attention  of  the  ordinary  patient. 
No  case  of  gonorrhea  should  be  discharged  as  cured  until  such  an 
examination  has  been  made  and  no  gonococci  found. 

Whenever  pus  is  discharged  from  the  prostate  in  considerable 
quantities,  abscess  of  the  gland  is  to  be  suspected,  and  in  each  case 
the  character  of  the  exudate  should  be  thoroughly  investigated. 
In  simple  inflammation  of  the  prostate,  as  a  rule,  but  Httle  pus  is 
present,  and  this  is,  for  the  most  part,  arranged  in  the  shred-like 
mucoid  masses  previously  described.  When  an  abscess  is  present, 
the  discharge  of  pus  is  much  more  abundant  and  may  practically 
be  continuous.  In  long-standing  simple  prostatitis,  whatever  its 
etiologic  origin,  members  of  the  colon  and  proteus  groups  of 
bacteria  are  commonly  present.  Absolute  identification  of  these 
organisms  is  possible  only  as  the  result  of  cultural  experiments; 
this  step  is,  however,  rarely  necessary  for  mere  clinical  purposes, 
since  the  morphologic  and  microchemic  characteristics  of  these 
organisms  are  usually  sufficient  for  their  identification.  When, 
however,  tubercular  disease  is  suspected,  a  special  examination 
should  be  made.  As  has  been  stated,  the  absolute  recognition  of 
the  tubercle  bacillus  is  occasionally  a  matter  of  difficulty  when 
staining  methods  alone  are  utihzed,  and  it  may  be  necessary 
to  resort  to  animal  inoculation,  but,  as  a  rule,  the  accompanying 
symptoms  aid  in  the  diagnosis.  Thus,  in  tubercular  prostatitis 
masses  of  necrotic  tubercular  tissue  may  be  discharged  from  the 
gland  into  the  urethra,  from  which  canal  they  may  be  washed  out 
by  the  urine  and  submitted  to  histologic  examination,  preferably 
by  the  antiformin  method. 

Vesiculitis. — The  specimens  intended  for  examination  are  to  be 
obtained  in  a  similar  manner  to  those  secured  from  the  prostate, 


EXAMINATION  OF  THE  URETHRAL  EXUDATE        1 39 

except  that  after  the  urethra  has  been  cleared,  massage  is  to  be 
applied  over  the  seminal  vesicles.  Inflammatory  disease  of  the 
seminal  vesicles  is  a  relatively  frequent  condition,  and  occurs  as 
a  compUcation  of  gonorrheal  urethritis.  The  normal  secretion 
of  the  seminal  vesicles  is  composed  of  a  mucoid  material,  desqua- 
mated cylindric  epithelium,  and  may  even  contain  a  few  corpora 
amylacea.  In  addition,  spermatozoa  in  greater  or  less  numbers 
can  always  be  expelled  from  the  seminal  vesicles.  When  the 
specimen  secured  after  massage  is  found  to  contain  no  spermato- 
zoa, it  is  probably  fair,  in  the  adult,  to  assume  that  some  obstruc- 
tion of  the  vas  on  that  side  exists  which  prevents  the  escape  of  sper- 
matozoa. 

The  methods  of  investigation  of  the  exudate  and  the  nature  of 
the  processes  being  similar  to  those  that  have  just  been  discussed 
in  regard  to  the  prostate,  no  further  description  is  necessary. 

Cowperitis. — Although  inflammation  of  Cowper's  gland  is  a  not 
uncommon  complication  of  urethritis,  and  the  body  of  the  gland 
oftens  remains,  for  a  long  time,  a  nidus  of  infection  in  which  gono- 
cocci  may  persist  indefinitely,  it  is  impossible  to  obtain  this  secre- 
tion unmixed  for  purposes  of  examination,  though  where  the 
duct  remains  permeable,  the  discharge  doubtless  escapes  into  the 
urethra. 

Examination  of  the  Seminal  Secretion 

Examination  of  the  seminal  secretion  is  not  only  of  utility  in 
diagnosing  diseased  conditions,  but  is  useful  also  to  determine  the 
normal  character,  to  establish  the  absence  or  presence  of  possible 
infecting  organisms,  to  demonstrate  the  presence  and  viability 
of  the  spermatozoa,  and  in  the  conduct  of  certain  medicolegal  in- 
vestigations. 

In  order  to  determine  the  viability  and  impregnating  powers 
of  the  spermatozoa  the  examination  should  be  made  as  soon  as 
possible  after  the  specimen  has  been  obtained.  These  qualities 
are  in  part  dependent  on  the  motility  of  the  spermatozoa,  and 
while  under  the  natural  conditions  of  warmth  and  moisture  in  the 
genital  tract,  these  bodies  may  remain  motile  for  hours  and  prob- 
ably for  days  or  even  weeks,  when  the  specimen  becomes  cold, 
or  when,  through  a  process  somewhat  analogous  to  clot  forma- 


140  EXAMINATION    OF    URINE   AND    URETHRAL   EXUDATE 

tion,  changes  in  the  chemic  nature  of  the  hquid  take  place,  Httle 
can  definitely  be  learned  as  to  the  vital  character  of  the  secretion. 
It  is  to  be  remembered  that  the  mere  recognition  of  seminal  fluid 
as  such  is  a  very  simple  matter.  Spermatozoa  may  be  demon- 
strated in  seminal  stains  months  old  on  removal  by  washing  in  salt 
solution. 

The  seminal  fluid  is  the  combined  secretion  of  several  glands, 
and  it  must  be  borne  in  mind  that  foreign  or  disease  elements  may 
enter  from  any  or  all  of  these.  As  received  in  the  vagina  of  the 
female,  the  seminal  secretion  is  made  up  of  spermatozoa  and  cells 
from  the  testicles,  mucoid  and  serous  secretion,  with  leukocytes 
and  epithelial  cells  from  the  seminal  vesicles  and  prostate  mingled 
with  Boettcher's  crystals,  mucus,  and  a  few  red  blood-cells  from 
ruptured  capillaries  from  the  glands  of  Cowper  and  from  the  numer- 
ous acini  of  Littre's  glands.  It  must  be  borne  in  mind  that  even 
though  viable  spermatozoa  are  demonstrable  in  the  secretion,  this 
is  not  proof  positive  that  they  may  impregnate  any  healthy  ovum, 
for  it  has  been  shown  definitely  that  certain  serum  affinities  are  also 
necessary  for  this  to  occur.  It  is  quite  possible  for  healthy  sper- 
matozoa to  be  destroyed  in  the  tract  of  healthy  females  where 
these  several  affinities  do  not  exist. 

Normalh^  the  fluid  is  alkaline  in  reaction,  and  gives  off  a  pecu- 
liar and  altogether  characteristic  odor.  It  produces  a  yellowish 
stain  on  white  fabrics.  Microscopically  the  fluid  can  be  identi- 
fied by  demonstrating  the  presence  of  spermatozoa.  This  is 
determined  most  easily  by  simply  placing  a  drop  of  the  fresh 
secretion  between  a  warm  slide  and  cover-glass,  when,  in  normal 
specimens,  examination  with  a  No.  6  or  7  lens  will  demonstrate 
the  presence  of  spermatozoa  in  very  great  numbers.  They  will  be 
seen  to  be  actively  motile,  their  serpentine  mode  of  progression 
being  very  characteristic.  Specimens  may  be  spread  on  a  slide, 
dried,  and  fixed  by  heat  or  by  means  of  methyl-alcohol,  formalin 
in  10  per  cent,  solution,  alcohol,  or  other  fixing  reagents.  Slides 
so  prepared  ma}^  then  be  stained  with  practically  any  of  the  chro- 
matic dyes,  of  which  methylene-blue,  fuchsin,  or  gentian- violet 
are  perhaps  the  best.  When  a  sightly  preparation  is  desired,  the 
specimens  may  be  stained  by  Boehmer's  hematoxylin  and  counter- 
stained  by  eosin. 

Chemically,  the  secretion  may  be  identified  by  the  use  of  Flor- 


EXAMINATION    OF    THE;   UR^THRAIv   EXUDATE  I4I 

ence's  reagent  (iodin,  2.54  gm.;  potassium  iodid,  1.63  gm.;  dis- 
tilled water,  30  c.c).  A  drop  of  this  reagent  is  added  to  the 
specimen,  and  the  mixture  is  placed  on  a  slide  and  examined 
under  low  power.  Dark-brown  crystals  are  formed,  some  of 
which  are  lance  shaped  and  arranged  in  rosets,  others  being  of  a 
rhomboid  or  pyramidal  shape.  Old  seminal  stains  also  respond 
to  this  reaction. 

In  spermatorrhea  the  sediment  of  the  urine  contains  spermato- 
zoa, leukocytes,  and  mucus;  these  may  readily  be  recognized  by 
making  a  microscopic  examination  of  the  fresh  specimen. 

Constant  absence  of  spermatozoa  from  the  seminal  secretion 
indicates  either  serious  disease  of  the  testicles  or  occlusion  of  the 
vas  or  some  other  portion  of  the  channel.  When  the  spermaatozoa 
are  found  only  in  small  numbers,  this  suggests  obliteration  of  the 
passage  on  one  side  or  perhaps  faulty  secretion.  Malformed 
spermatozoa  are  seen  in  many  general  and  local  diseases  of  the 
testis.  In  excessive  stimulation  of  the  sexual  function  the  sper- 
matozoa are  found  in  diminished  numbers,  the  motility  is  less  active, 
and  many  of  the  cells  present  exhibit  defects  of  development.  One 
of  the  most  frequent  of  these,  in  the  writers'  experience,  is  a  faulty 
development  of  the  tail  of  the  cell,  which  may  be  present  only  as  a 
short,  stump-like  appendage.  The  head  of  the  cell  also  presents 
many  variations  in  these  cases,  one  of  the  most  common  being 
that  it  has  a  spheric  instead  of  an  ovoid  shape,  and  that  it  is,  as 
a  rule,  considerably  larger  than  normal;  chromatic  stains  also 
show  a  lack  of,  or  the  presence  of  abnormal  chromatic  elements 
in  this  body. 

Red  blood-cells  are  found  normally  in  greater  or  less  numbers 
in  the  seminal  secretion,  but  when  inflammatory  conditions  are 
present  in  any  portion  of  the  genital  tract,  the  amount  of  blood 
may  become  much  increased — so  much  so,  in  fact,  that  it  is  readily 
seen  with  the  naked  eye. 

Pus  appears  in  the  semen  in  suppurative  disease  of  any  portion 
of  the  tract,  but  is  comparatively  rare  in  actual  suppurations  of 
the  testis,  the  lumen  of  the  vas  on  the  diseased  side  being  com- 
monly obHterated  in  these  instances.  For  this  reason  it  is  rarely 
possible  to  diagnose  the  character  of  the  testicular  inflammation 
from  an  examination  of  the  secretion,  except  when  other  por- 
tions of  the  genital  tract  are  similarly  involved.     When,  how- 


142  EXAMINATION    OF    URINE   AND    URETHRAL    EXUDATE 

ever,  the  secretion  is  found  to  contain  pus  or  other  abnormal  ele- 
ments, the  tests  previously  mentioned  should  be  applied,  although 
positive  results  in  most  cases  point  to  disease  outside  of  the  testicle. 
Urorrhea. — In  this  condition,  due  to  excessive  activity  of  the 
urethral  glands,  the  absence  microscopically  of  any  other  elements 
renders  the  diagnosis  easy,  the  secretion  from  the  urethral  glands 
consisting  of  long,  slender,  urethral  threads  of  mucus,  epithelium, 
and  a  few  leukocytes. 


Fig.  69. — Smear  from  the  vaginal  discharge  of  a  gonorrheal  woman,  shortly  after  coitus, 
showing  the  presence  of  pus-cells,  desquamated  vaginal  epithelium,  and  spermatozoa,  a. 
Pus-cells  with  gonococci ;  b,  pus-cells  without  gonococci ;  c,  gonococci  in  mucoid  dis- 
charge ;  rf,  desquamated  vaginal  epithelium  ;  e,  spermatozoa  ;  f,  red  blood-cells. 


Examination    of    Secretions    and    Exudates    from    the 
Female  Genitals 

The  examination  of  these  secretions  is  of  particular  importance 
only  in  cases  of  suspected  infectious  disease.  In  these  instances 
the   examination   must,   in   every  instance,  be  very  thoroughly 


PLATE  V 


be; 


bo 


EXAMINATION  OF  THE  URETHRAL  EXUDATE        1 43 

made,  and  the  physician  must  not  content  himself  with  examining 
a  single  specimen  of  exudate  taken  from  any  one  portion  of  the 
vulva  or  vagina.  In  the  case  of  suspected  gonorrhea,  particu- 
larly, the  examination  should  be  systematic,  and  should  begin 
with  exposure  of  the  cervix  uteri  and  inspection  and  microscopic 
examination  of  the  cervical  secretion.  This  is  normally  a  clear 
mucoid  material,  resembling  the  white  of  an  e^gg.  Under  many 
physiologic  conditions,  as  just  before,  during,  and  after  menstrua- 
tion, this  secretion  becomes  turbid  from  the  presence  of  broken- 
down  blood,  leukocytes,  and  necrotic  endometrium.  When  in- 
flammatory disease  of  either  the  cervical  glands  or  the  endome- 
trium is  present,  the  cervical  discharge  becomes  more  or  less  tur- 
bid and  white,  yellowish,  or  green  in  color,  according  to  the  organ- 
isms present.  Examination  of  smears  of  this  discharge,  as  of  the 
exudate  of  the  male  urethra,  reveals  the  nature  of  the  organisms 
involved  in  the  process.  Cervical  gonorrhea  is  not  frequent, 
except  in  acute  cases  or  when  a  gonorrheal  endometritis  or  salpin- 
gitis is  present,  when  the  secretion  may  trickle  down  from  above. 

Normally  the  vaginal  secretion  is  small  in  amount,  and  con- 
sists chiefly  of  desquamated  epithelial  cells  of  the  squamous 
variety  and  of  serum  and  mucus.  In  inflammatory  diseases 
there  are  added  to  these  pus  or  leukocytes,  and  in  active  cases 
blood  and  such  bacteria  as  are  primarily  or  secondarily  concerned 
in  the  process. 

Diffuse  gonorrheal  vaginitis  is  rare,  except  in  those  cases  of 
acute  infection  in  which  the  process  involves  all  portions  of  the  tract. 

The  chief  site  of  persistent  chronic  gonorrheal  infection  in  the 
female  is  the  vulvovaginal  gland,  and  in  all  suspected  cases  the 
secretion  should  be  expressed  from  these  saccules  and  examined 
microscopically.  It  must  be  remembered,  as  was  stated  in  con- 
sidering the  examination  of  chronic  discharges  in  the  male,  that 
in  chronic  gonorrhea  of  the  glands  of  Bartholin  the  gonococci  do 
not  at  all  times  present  typical  forms,  but  involution  types  only 
may  be  seen. 

In  vulvitis  the  discharge  from  about  the  urethra  should  always 
be  examined,  as  frequently  the  folds  of  mucosa  about  this  orifice 
harbor  infectious  material.  Similarly,  the  sebaceous  secretion 
about  the  prepuce  and  clitoris  should  also  be  examined. 


144         IJXAMINATION   OF   URINB   AND    URETHRAL    EXUDATE 

The  small  glands  situated  in  either  lip  of  the  urethra  should  be 
particularly  inspected,  for  they  alone  may  be  found  infected. 

In  all  cases  it  must  be  remembered  that  the  secretion  of  the 
external  female  genitals  may  be  said  normally  to  harbor  bacteria, 
but  the  organisms  usually  found  here  are,  for  the  greater  part, 
members  of  the  putrefactive  group,  and  have  but  little  clinical 
significance.  Infection  and  vulvitis  caused  by  intestinal  bacteria 
are  obviously  likely  to  take  place,  particularly  where  proper 
cleanliness  of  these  parts  is  not  observed. 

Method  of  Procedure  for  the  Complement-fixation  in  Gonorrhea. — 
The  method  is  somewhat  similar  to  the  Wassermann  technic,  with 
the  exception,  of  course,  that  the  antigen  employed  is  an  extract  of 
the  gonococcus  organism.  Simple  methods  of  extracting  are 
employed,  the  most  direct  of  which  is  the  growing  of  gonococci  of 
several  strains  on  veal-ascitic-agar,  salt  free.  The  forty-eight-hour 
growth  is  washed  off  with  sterile  water  and  the  emulsion  is  then 
autolysed  in  the  ice-box  for  several  hours  or  in  a  water-bath  at  56° 
C.  for  two  hom-s.  This  is  then  filtered  through  a  Berkefeld  filter  and 
its  antigenic  properties  are  titrated.  The  reaction  is  usually  done 
in  ^Iq  or  ^  volume  of  that  employed  in  the  original  Wassermann. 

In  acute  anterior  gonorrhea  this  test  is  of  no  value.  In  posterior 
gonorrhea,  with  its  various  local  complications,  it  is  more  useful, 
and  is  generally  considered  accurate  when  positive,  but  negligible 
when  negative.  This  test  may  be  very  valuable  in  the  diagnosis  of 
abscess  or  hidden  cases  of  chronic  infection,  but  must  not  be  con- 
sidered as  accurate  negatively.  Generally  speaking,  the  test  wiU 
usually  show  whether  a  patient  who  has  had  gonorrhea  is  cured  or 
not.  A  positive  reaction  may  be  considered  as  at  least  indicating 
that  a  man  has  had  gonorrhea,  but  we  are  unprepared  to  assert  that 
the  reaction  may  not  be  sometimes  given  in  clinically  cm-ed  cases. 

Examination  for  the  Spiroch^ta  Pallida 
There  can  no  longer  be  question  as  to  the  relationship  between 
the  spirochaeta  pallida  of  Hoffman  and  Schaudinn  and  syphilis. 
That  this  is  the  sole  and  essential  organism  concerned  in  the 
production  of  syphilis  has  not  as  yet  perhaps  been  demonstrated 
absolutely  theoretically,  but  clinically  no  doubt  can  now  exist. 


EXAMINATION   OI^    THE    URETHRAL   EXUDATE  145 

In  order  to  demonstrate  the  presence  of  this  organism  a  certain 
amount  of  technical  skill  is  demanded,  and  negative  findings  can- 
not always  be  considered  as  of  much  import,  since  errors  of  tech- 
nic  are  so  frequent;  practice,  nevertheless,  renders  the  technical 
difficulties  fewer  and  more  easily  surmounted.  Besides,  the  pos- 
sibility of  forming  an  early  correct  diagnosis  is  often  well  worth 
the  time  and  trouble  necessary  for  demonstrating  the  presence 
of  the  organism. 

Although  methods  for  the  successful  culture  of  this  germ  have 
been  discovered,  and  animal  inoculation  is  no  longer  especially 
different,  it  is  usually  necessary  for  us  to  rely  chiefly  on  the  mor- 
phologic aspects  for  diagnosis.  These  are  at  times  misleading, 
for  the  germ  may,  unfortunately,  be  confused  with  other  spiro- 
chetse;  by  practice,  however,  the  examiner  will  be  enabled  to 
readily  exclude  most  of  these  organisms. 

The  m.ode  in  which  the  material  is  collected  for  examination 
is  of  the  greatest  importance,  for  unless  great  care  is  exercised  to 
free  the  specimen  from  blood  and  pus,  the  demonstration  of  the 
spirillum  is  rendered  more  difficult. 

The  surface  of  the  suspected  primary  or  secondary  lesion  should 
be  cleansed  thoroughly  from  blood  and  exudate,  and  the  investing 
epithelium  should  be  carefully  curetted  away.  A  small  drop  of 
the  exuding  serum  is  then  collected  directly  on  the  surface  of  a 
thoroughly  clean  slide,  or  it  may  be  transferred  to  the  slide  by  a 
sterile  platinum  loop — it  is  absolutely  necessary  that  the  smear 
be  made  as  thin  as  possible.  A  drop  of  serum  may  also  be  secured 
from  a  suspected  lymph-node  by  means  of  a  hypodermatic  needle 
and  aspiration.  The  cover-glass  preparation  is  then  allowed  to 
dry  in  dust-free  air. 

Several  methods  of  staining  have  been  successfully  employed, 
but  most  of  them,  such  as  the  method  of  Giemsa,  by  which  the 
organism  was  first  successfully  demonstrated,  are  long  and  com- 
plicated. The  writers  have  found  the  method  of  Goldhorn 
by  far  the  most  satisfactory.  This  consists  in  the  use  of  Gold- 
horn's  preparation  of  polychrome  methylene-blue.^  Other  poly- 
chrome dyes  may  now  also  be  similarly  employed. 

1  The  methods  for  preparing  this  were  detailed  in  the  "Journal  of  Experi- 
mental Medicine,"  March,  1906;  also  in  less  detail  in  the  "  N.  Y.  Post-Grad- 
uate,"  February,  1906. 


146  EXAMINATION    OF    URINE   AND    URETHRAL    EXUDATE 

A  small  amount  of  the  dye  is  dropped  on  the  specimen  without 
previous  fixation,  and  after  two  or  four  seconds  it  is  poured  off 
and  the  preparation  slowly  immersed  in  water.  It  is  important, 
in  doing  this,  to  prevent  the  deposition  of  sediment  on  the  speci- 
men; the  slide  must  hence  be  introduced  into  the  water  in  a 
slanting  direction,  with  the  preparation  side  down;  after  a  second 
or  two  the  slide  may  be  waved  to  and  fro  until  it  is  free  from  stain, 
when  it  should  be  removed  from  the  water  and  placed  in  a  slanting 
position  to  drain.  It  is  allowed  to  dry  naturally,  but  it  is  im- 
portant that  the  air  of  the  room  be  free  from  dust,  or  the  resulting 
specimen  will  be  difficult  to  study. 

The  organism  will  be  seen  as  a  very  faintly  stained  spirillum, 
characterized  by  its  more  or  less  sharp-pointed  ends  and  by  its 
acute  angular  flexures  or  turns.  It  varies  in  length  from  half 
that  of  a  red  corpuscle  to  as  much  as  25  microns.  When  stained 
in  the  manner  directed,  the  germ  is  of  a  purplish -black  color; 
it  can  be  rendered  a  deep  black  by  washing  the  stained  specimen 
for  from  ten  to  fifteen  seconds  in  Gram's  iodin  solution.  The 
specimen  is  mounted  and  examined  with  an  oil-immersion  lens 
in  the  usual  manner ;  a  persistent  search  is  often  necessary  to 
reveal  the  presence  of  the  spirillum.  Impregnation  staining 
methods  employing  solutions  of  silver  nitrate  and  subsequent 
exposure  to  light  are  now  used  with  great  success  and  supply  us 
with  a  more  simple  means  for  the  recognition  of  the  organism. 
For  examination  of  smear  preparations,  however,  the  polychrome 
dyes  have  as  yet  proved  most  accurate  in  our  hands,  but  for 
section  staining  the  silver  nitrate  methods  are  most  satisfactory. 

Dark  field  illumination,  which  requires,  however,  special  but 
not  excessively  expensive  apparatus,  makes  it  possible  to  easily 
and  quickly  demonstrate  the  organism  in  fresh  and  unstained 
specimens. 

The  great  diagnostic  accuracy  of  the  Wassermann  and  Noguchi 
serum  reactions  in  all  stages  of  syphilis  have  rendered  search  for 
spirochaetae  somewhat  less  necessary  than  formerly.  Still  in  the 
primary  and  secondary  stages  of  the  disease  the  demonstration 
of  the  organism  is  generally  easier,  quicker,  and  more  definite. 


CHAPTER  V 

THE  KIDNEY:    ITS  EMBRYOLOGY,  ANATOMY,  AND 
PHYSIOLOGY 

EMBRYOLOGY 

In  the  development  of  the  body  the  kidney  is  preceded  by  the 
formation  of  two  kidney-hke  structures  in  the  intermediate  cell 
mass,  the  pronephros  and  the  mesonephros,  both  of  which  originate 
from  portions  of  the  Wolffian  body.  These  organs  contain  glomer- 
uli and  tubules,  not  unhke  those  subsequently  seen  in  the  true 
kidney,  and  open  into  the  Wolffian  duct.  In  the  male  the  nephros 
later  becomes  atrophied,  but  persistent  remains  form  the  parova- 
rium in  the  female,  and  parts  of  the  epididymis  in  the  male. 

The  anlage  for  the  true  kidney,  or  metanephros,  appears  during 
about  the  seventh  week  of  intra-uterine  life.  Its  mode  of  develop- 
ment is  very  similar  to  that  of  the  Wolffian  body,  and  it  is  simi- 
larly formed,  chiefly  in  the  intermediate  cell-mass  of  the  meso- 
derm. The  tubules  are  shaped  within  this  tissue,  appearing  first 
as  blind  sacculations  in  the  formation  of  which  the  primitive  peri- 
toneum now  appears  to  take  no  part.  One  extremity  of  each 
tube  becomes  dilated  into  a  spheric  body,  into  which  capilla- 
ries grow,  thus  invaginating  the  walls  of  the  spherule,  and  so 
forming  the  Malpighian  body  and  the  capsule  of  Bowman.  Only 
the  cortical  portions  of  the  kidneys  are  developed  from  the  inter- 
mediate cell-mass  in  this  manner.  The  pelvis,  the  medulla,  and 
the  ureters  are  formed  from  protrusions  of  the  posterior  extremity 
of  the  dilated  Wolffian  duct ;  these  outgrowths  pass  toward  the 
intermediate  mass,  and  subsequently  the  tubules  of  the  cortex 
unite  with  those  that  represent  the  conducting  portions  of  the 
urinary  passages,  which  are  thus  derived  from  entirely  different 
structures.  McMurrich  states,  however,  that  the  entire  renal 
tubule  is  derived  from  this  outgrowth  of  the  Wolffian  duct,  and 
that  the  intermediate  cell-mass  contributes  only  the  supporting 
tissue  and  the  blood-vessels. 

147 


148 


the;  kidney 


The  glomeruli  appear  at  about  the  eighth  week,  and  in  the  third 
month  the  papillae  are  formed  (Ouain).  At  about  the  tenth  week 
the  surface  of  the  kidney  becomes  lobulated.  The  further  develop- 
ment and  elaboration  proceeds  along  the  lines  of  simple  growth. 


ANATOMY 

The  kidneys  are  two  bean-shaped  organs,  lying  in  the  posterior 

portion  of  the  abdominal  cavity, 
outside  the  peritoneum,  one  being 
on  each  side  of  the  spinal  column, 
and  on  a  level  with  the  last  dorsal 
and  the  upper  two  or  three  lumbar 
vertebrae.  Usually  the  right  kidney 
lies  somewhat  lower  than  the  left, 
probably  due  to  the  pressure  on  this 
side  exerted  by  the  right  lobe  of  the 
liver,  the  inferior  surface  of  which 
frequently  presents  a  depression 
corresponding  to  its  point  of  appli- 
cation to  the  kidney. 

The  kidneys  are  so  arranged  in 
the  abdominal  cavity  that  their  an- 
terior surfaces  are  slightly  everted, 
looking  forward  and  outward,  their 
posterior  aspects  being  correspond- 
ingly arranged  in  the  contrary 
planes.  The  normal  kidney  has  an 
average  size  of  about  four  inches 
in  length;  two  and  a  half  inches 
in  breadth;  and  one  and  a  quarter 
to  one  and  a  half  in  thickness 
(Quain) ;  as  a  rule,  however,  the 
right  kidney  is  somewhat  longer  and 
thinner  than  the  left.  The  average  weight  is  about  four  and  one- 
half  ounces,  but  both  size  and  weight  vary  quite  constantly,  under 
normal  conditions,  with  the  body  weight;  thus  the  largest  kid- 
neys are  generally  seen  in  the  largest  bodies.  Probably  on  account 
of  this  fairly  definite  relationship  between  body  weight  and  the 


Fig.  70. — Longitudinal  section  of 
human  fetus  of  twenty-six  days'  gesta- 
tion, showing  the  pronephros  or  earliest 
anlage  of  renal  tissue,  a.  Wolffian 
duct ;  d,d,  developing  glomeruli  of  pro- 
nephros ;  c,  neural  canal ;  d,  posterior 
root  ganglion.     Authors'  specimen. 


ANATOMY 


149 


size  of  the  renal  organs  the  average  size  of   the  kidney  in   the 
female  is  somewhat  smaller  than  that  of  the  male. 

The  kidneys  lie  posterior  to  the  peritoneum;  the  anterior  sur- 
faces are  directly  covered  by  this  membrane,  except  in  stout 
subjects,  where  separation  by  a  deposit  of  fat  over  the  anterior 
surface  of  the  kidneys  often  occurs  in  marked  degree.  The  other 
aspects  of  the  kidney  are,  in  well-nourished  subjects,  embedded 


Fig.  71. — Kidney  from  a  human  fetus  of  four  months'  gestation,  indicating  the  differentiation  in 
development  between  the  cortex  and  medulla.     Authors'  specimen. 


in  a  thick  layer  of  adipose  and  areolar  tissue,  which  serves  to  retain 
the  organ  in  place  and  doubtless  acts  as  a  very  efficient  protective 
layer  or  insulator,  particularly  against  sudden  chills  or  trauma. 

The  surface  of  the  adult  human  kidney  is  smooth  and  of  a  deep- 
red  color.  Not  infrequently,  however,  it  is  seen  to  be  more  or  less 
lobulated,  simulating  the  kidneys  of  the  fetus  and  certain  of  the 
lower  animals. 

Anteriorly,  the  left  kidney  region  is  crossed  by  the  pancreas,  and 
the  splenic  vessel  hes  just  about  at  the  level  of  the  hilum.     Above, 


150  THE    KIDNEY 

it  lies  behind  a  portion  of  the  stomach  and  a  few  coils  of  small 
intestine. 

The  right  kidney  is  situated  posterior  to  a  portion  of  the  duo- 
denum, whereas  the  ascending  colon  on  the  right  side  and  the 
splenic  flexure  and  descending  colon  on  the  left  are  found  at  the 
lower  and  outer  parts  of  the  right  and  left  organs  respectively. 
The  upper  portions  of  both  kidneys  are  surmounted  by  the  adrenal 
bodies. 

When  in  their  normal  position,  the  kidneys  cannot  ordinarily 
be  palpated  in  well-nourished  subjects.  In  emaciated  individuals 
or  in  those  in  whom  the  abdominal  walls  are  very  much  relaxed, 
the  kidneys  may  be  felt  on  deep  palpation,  particularly  when 
they  have  left  their  proper  position  and  taken  a  lower  one.  Renal 
palpation,  however,  becomes  easier  as  experience  is  gained. 

The  blood-supply  of  the  kidneys  is  derived  from  the  short  and 
nearly  straight  renal  arteries,  which  are  given  off  directly  from 
the  aorta.  As  a  result  of  this  anatomic  arrangement  it  will  be 
seen  that  the  kidneys  receive  a  very  direct  blood-supply,  and  one 
in  which  the  pressure  is  practically  the  same  as  that  in  the  aorta. 
The  large  size  of  these  arteries  also  insures  an  abundant  blood- 
supply  for  these  organs.  The  renal  arteries  are,  however,  some- 
what protected  from  the  direct  systolic  blow  of  the  heart  by  a 
very  thick  and  well-developed  tunica  media,  the  amount  of  blood 
entering  them  being  also  in  part  thus  controlled.  The  blood  is  re- 
turned from  the  kidneys  by  the  large  renal  veins,  which  enter  di- 
rectly into  the  inferior  vena  cava.  In  addition  to  this  blood-supply 
the  kidneys  also  receive  a  certain  amount  of  blood  through  small 
vessels  that  penetrate  the  capsule  from  the  surrounding  areolar 
tissue,  anastomosing  with  the  terminals  of  the  interlobular  arte- 
rioles. A  venous  return  also  takes  place  along  the  same  channels. 
Under  normal  conditions  this  additional  blood-supply  is  relatively 
unimportant,  but  in  some  diseased  states  it  mav  become  of  con- 
siderable value,  serving  at  such  times  to  nourish  the  organs  and 
even  perhaps  to  maintain  a  certain  amount  of  renal  excretion,  as, 
for  example,  in  thrombosis  of  the  renal  artery. 

The  lymphatics  of  the  kidney  are  made  up  of  a  deep  and  a  super- 
ficial set.  Uniting  with  those  of  the  adrenal  bodies,  they  pass 
toward  the  median  line  along  the  course  of  the  renal  blood-vessels. 


ANATOMY  151 

where  they  drain  into  a  group  of  lymph-nodes  that  He  about  those 
vessels  and  that  are  connected  with  the  lumbar  retroperitoneal 
lymph-nodes. 

The  sensory  nerve-supply  of  the  kidneys  is  probably  derived 
from  the  tenth,  eleventh,  and  twelfth  dorsal  spinal  nerve-trunks, 
the  fibers  being  transmitted  through  the  sympathetic  plexuses 
(Head).  By  far  the  more  important  nerve-supply  for  the  kidney, 
however,  is  that  which  controls  the  vasomotor  impulses;  both 
constrictor  and  dilator  fibers,  according  to  Bayliss  and  Sterling, 
probably  originate  from  the  dorsal  nerves  from  the  sixth  spinal 
segment  downward.  Constrictor  fibers  are  also  probably  derived 
from  the  two  upper  lumbar  trunks.  All  these  fibers  probably  blend 
in  the  ganglia  of  the  renal  plexuses. 

Structurally,  the  kidney  is  a  highly  modified  compound  tubular 
gland.  Much  of  its  finer  construction,  especially  the  gross  dis- 
tribution of  the  tissues  that  carry  on  the  specialized  functions  of 
the  organ,  is  apparent  to  the  unaided  eye.  Anatomically,  the 
viscus  may  readily  be  divided  into  the  capsule,  the  cortex,  the 
medulla,  and  the  pelvis. 

The  fibrous  capsule  that  incloses  the  kidney  can,  when  the 
organ  is  normal,  be  separated  from  the  cortex  of  that  organ 
with  but  little  difficulty.  This  capsule  is  loosely  united  to  the 
surrounding  adipose  tissue  in  which  the  organs  are  embedded,  and 
is  made  up  of  a  fairly  thin  layer  of  mixed  connective  tissue  and  a 
thin  stratum  of  smooth  muscle  that  incloses  the  entire  organ, 
being  attached  to  the  cortex  by  delicate  strands  of  connective 
tissue  that  convey  minute  blood-vessels.  At  the  hilum  the  cap- 
sule becomes  continuous  with  the  adventitia  of  the  renal  vessels. 

The  cortex  is  made  up  of  a  layer  of  dark-red  tissue,  about  one- 
half  inch  in  thickness,  that  surrounds  the  central  portion  of  the 
organ  except  at  the  hilum,  where  it  first  becomes  thin  and  then 
disappears.  Projecting  up  into  the  cortex  from  the  medulla 
are  bands  of  striations  that  extend  nearly,  but  not  quite  through, 
the  cortical  tissue;  these,  from  their  fascicular  appearance,  are 
known  as  the  medullary  rays.  The  remainder  of  the  cortex  is 
composed  of  the  labyrinth,  and  it  is  in  this  portion  of  the  kidney 
that  its  most  important  activities  take  place. 

The  medulla  of  the  kidney  is  formed  by  the  pyramids  and  the 


152  THE    KIDNEY 

columns  of  Bertini.  The  pyramids  are  masses  of  tissue  that,  to 
the  unaided  eye,  show  a  coarse  striation  radiating  from  the  bases, 
which  He  against  the  cortex,  toward  the  apex  of  the  pyramid. 
When  divided  either  longitudinally  or  transversely  the  pyramids 
resemble  in  appearance  a  miniature  fan,  the  framework  of  which 
is  represented  by  the  radiating  striations.  The  narrow  tongues  of 
striation,  the  medullary  rays,  which  are  continued  into  the  cortex 
and  which  have  just  been  described,  are  simply  narrow  prolonga- 
tions of  the  pyramidal  structure  into  the  cortex.  The  columns 
of  Bertini  are  strands  of  connective  tissue  that  support  the  blood- 
vessels and  lymphatics  as  they  pass  from  the  central  portion  of 
the  kidney  toward  the  cortex;  to  the  naked  eye  they  appear  as 
continuations  of  the  cortex,  highly  vascularized,  dipping  down 
between  the  pyramids. 

The  pelvis  of  the  kidney  is  a  large,  funnel-shaped  receptacle 
whose  narrowest  portion  begins  at  the  hilum,  spreading  out  at  its 
base  into  bay-like  dilatations  known  as  the  calices,  into  which 
the  papillae  of  the  pyramids  open — usually  only  one,  but  two  or 
three  may  open  into  the  calyx.  The  pelvis  is  lined  by'  a  layer 
of  transitional  epithelium  that  is  continued  over  the  papillse. 
It  is  supported  by  a  basement  membrane  of  connective  tissue, 
over  which  is  arranged  a  longitudinal  and  a  circular  stratum  of 
smooth  muscle — a  continuation  of  the  muscle  layers  of  the  ure- 
ter. The  coats  are  completed  by  an  outer  fibrous  sheath  in  the 
structure  of  which  many  yellow  elastic  fibers  enter. 

Microscopically,  the  greater  bulk  of  the  renal  tissue  is  made  up 
of  long  epithelial  tubes  (highly  modified  tubular  glands)  that 
secrete  the  urine  and  conduct  it  to  the  pelvis  of  the  kidney.  Every 
urinary  tubule,  it  must  be  remembered,  is  not  thus  fully  devel- 
oped, for  they  vary  greatly  in  length,  many  being  quite  short. 

The  urinary  tubule  begins  in  the  labyrinth  of  the  cortex  as  the 
capsule  of  Bowman,  which  is  formed  of  the  dilated  and  invagi- 
nated  end  of  the  tube.  The  cavity  thus  formed  is  occupied  by  a 
tuft  of  capillaries.  The  capsule  of  Bowman  is  lined  down  as  far 
as  the  constriction,  known  as  the  neck,  by  a  layer  of  thin  simple 
squamous  epithelium.  The  entire  mass  of  capillaries  and  its  epi- 
thelial envelop  are  known  as  theMalpighian  body.  Below  the  neck 
(a  narrow  straight  passage  fined  by  small  cubical  cells)  the  tubule 


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■i-j 

ANATOMY  153 

opens  out  into  a  wider  channel,  lined  by  larger  cubical  or  columnar 
epithelium  and  thrown  into  many  folds;  this  portion,  which  is 
still  contained  in  the  labyrinth,  constitutes  the  proximal  convoluted 
tubule.  The  tube  then  enters  the  medullary  ray,  passing  down- 
ward toward  the  medulla  in  a  tortuous  manner,  where  it  is  known 
as  the  spiral  tube.  As  it  approaches  the  juncture  of  the  cortex 
and  the  pyramid  the  tube  suddenly  narrows,  its  epithelium  now 
being  made  up  of  flattened  cells  with  larger  nuclei;  this  portion 
constitutes  what  is  known  as  the  descending  limb  of  Henle.  After 
continuing  downward  for  a  certain  distance  within  the  pyramid 
the  tube  becomes  larger,  its  epithehum  cubical,  and  it  curves  on 
itself,  forming  the  loop  of  Henle;  it  is  then  continued  upward, 
being  lined  by  cubical  cells  until  it  again  passes,  now  as  the  ascend- 
ing limb  of  Henle,  into  the  cortex,  as  an  irregular  convoluted 
tube  of  larger  lumen  known  as  the  irregular  tubule.  This  chan- 
nel leads  directly  into  a  tube  precisely  similar  in  structure  to  the 
first  or  proximal  convoluted  tubule,  and  known  as  the  distal 
or  second  convoluted  tube.  This  leads  through  the  arched  collect- 
ing tubule  toward  the  medullary  rays,  where  it  empties  into  a 
tube  of  free  lumen,  lined  by  cubical  epithelium,  named  the  col- 
lecting tubule.  The  collecting  tubules  unite  to  form  other  and 
larger  ducts,  all  continuing  downward  toward  the  urinary  papilla, 
where  they  finally  open  out  into  the  pelvis  of  the  kidney. 

The  minute  anatomy  of  the  blood-supply  of  the  kidney  is  of  con- 
siderable importance  for  the  correct  understanding  of  renal  disease. 
As  the  renal  artery  enters  the  hilum  of  the  kidney  it  commonly 
breaks  up  into  two  or  more  smaller  trunks,  which  pass,  external 
to  the  sheath  of  the  pelvis,  toward  the  columns  of  Bertini,  where 
they  again  form  smaller  trunks,  at  least  one  of  which  is  continued 
up  toward  the  cortex  through  the  column.  At  the  junction  of 
cortex  and  medulla  anastomosing  lateral  branches  are  given  off, 
forming  a  series  of  vascular  arches  known  as  the  arterial  arcade. 
From  these  small  branches,  the  arteria  rectae,  which  pass  straight 
downward  through  the  pyramids,  supplying  their  nourishment, 
are  given  off.  Another  series  of  branches  pass  upward,  where 
they  are  distributed  to  the  tissues  of  the  cortex.  As  the  trunks 
course  upward  they  give  off  lateral  branches,  which  become 
smaller  and  smaller,  finally  terminating  just  beneath  the  capsule. 


154  the;  kidney 

The  lateral  branches  pass  to  the  capsules  of  Bowman,  which  they 
enter,  then  break  up  into  a  complicated  mass  of  anastomosing 
capillaries — the  glomerulus.  The  entering  arteriole  is  known  as 
the  afferent  artery,  and  the  blood,  still  arterial,  is  collected  from 
the  Malpighian  bodies,  leaving  it  in  a  separate  arteriole,  the 
efferent  artery.  The  efferent  artery  then  passes  to  the  convo- 
luted tubules,  about  which  it  breaks  up  into  a  very  complicated 
capillary  network.  The  blood  from  these  capillaries  is  collected 
by  a  vein  that  empties  into  successively  larger  venules  and  veins, 
corresponding  in  name  and  location  to  the  accompanying  arteries, 
finally  escaping  from  the  kidney  through  the  renal  vein.  The 
capillaries  of  the  minute  terminal  arterioles  that  penetrate  to  the 
capsule  nourish  this  structure  and  then  return  the  blood  by  a 
corresponding  venous  tract.  Occasionally,  particularly  under 
diseased  conditions,  these  vesssels  may  anastomose  with  trunks 
penetrating  from  the  areolar  tissue  surrounding  the  kidney;  in 
this  manner  a  secondary  and  distinctly  separate  blood-supply 
of  the  kidney  is  formed. 


PHYSIOLOGY 

The  kidney  is  the  chief  excretory  organ  of  the  body.  Although 
other  organs,  more  especially  the  skin  and  bowel,  are  concerned 
in  the  work  of  excretion,  experimental  and  cHnical  observation 
has  demonstrated  that  the  presence  of  renal  tissue  is  necessary 
for  the  maintenance  of  life,  and  that  a  certain  and  quite  definite 
amount  of  kidney  substance  must  be  present.  Thus  it  has  been 
shown  that  if  an  amount  of  kidney  substance  equal  to  three-fourths 
of  the  entire  weight  of  the  organs  be  removed,  death  follows. 
This  occurs  even  though  the  amount  of  water,  urea,  and  other 
urinary  salts  be  increased,  in  partial  extirpation  of  the  kidney,  and 
it  may  be  taken  as  an  indication  that,  in  addition  to  its  excretory 
function,  the  kidney  is  also  concerned  in  some  internal  secretory 
process  that  is  essential,  in  part  at  least,  for  the  maintenance  of 
life. 

It  was  formerly  believed  that  the  kidney  merely  served  as  a 
filter  for  the  blood  of  the  body;  repeated  studies  have,  however, 
demonstrated  beyond  question  that  its  function  is  far  more  com- 


PHYSIOLOGY  155 

plicated,  though  governed  in  large  degree,  nevertheless,  by  the 
state  of  the  blood-vessels,  the  pressure  in  them,  and  the  amount 
and  character  of  the  circulating  blood.  Starling,  of  late,  has  in 
particular  shown,  both  experimentally  on  animals  and  in  man  as 
well,  that  the  kidney  automatically  adjusts  its  relative  excretion 
to  the  momentary  needs  of  the  body.  Thus,  where  water  is 
introduced  in  overabundance,  the  excretion  of  water  by  the 
kidney  is  heightened,  or  if  various  salts  become  relatively  too 
abundant,  these  bodies  are  automatically  thrown  out  with  greater 
relative  rapidity.  This  vital  adjustment  of  the  kidney  to  the 
special  needs  of  each  individual  has  been  most  decisively  demon- 
strated by  Starling  and  his  pupils. 

Unquestionably,  the  greater  part  of  the  water  and  inorganic 
salts  of  the  urine  are  excreted  by  the  action  of  the  Malpighian 
bodies.  It  is  still  an  unsettled  question  as  to  whether  the  secre- 
tion of  these  constituents  of  the  urine  is  entirely  a  mechanic 
process, — one  of  osmosis  dependent  solely  on  blood  pressure, 
osmotic  tension,  and  on  the  rapidity  of  the  circulation, — orwhether, 
in  addition  to  this,  the  cells  of  the  capsule  of  Bowman,  and  perhaps 
those  of  the  capillary  tuft  also,  take  an  active  part  in  the  excretory 
process.  There  is  little  doubt,  however,  but  that  the  chief  function 
of  the  Malpighian  bodies  is  a  mechanic  and  not  a  secretory  one,  and 
in  those  conditions  in  which  the  excretion  of  fluid  and  inorganic 
salts  is  defective,  the  lesions  are  chiefly  found  in  the  circulatory 
mechanism  of  the  Malpighian  bodies.  A  direct  relationship 
between  blood  pressure,  for  example,  and  the  watery  secretion 
of  the  urine  has  been  thoroughly  established.  In  addition,  how- 
ever, a  large  amount  of  the  albumin  in  albuminuria  and  of  the 
sugar  in  glycosuria  is  probably  excreted  through  the  Malpighian 
bodies,  and  it  is  likely  that  in  these  conditions  at  least  the 
epithelium  of  the  capsule  of  Bowman  does  play  an  active  secretory 
role. 

Abundant  researches  have  shown  that  the  epitheUum  of  the 
convoluted  tubules —  and  with  these  we  include  the  spiral  and  the 
irregular  tubules — is  active  in  the  excretion  of  urea  and  allied  bodies. 
Relatively,  the  function  of  these  portions  of  the  renal  parenchyma 
is  more  important  than  is  that  of  the  Malpighian  bodies,  for  urea 
and  its  alHed  substances  constitute  the  most  important  waste- 


156  THE    KIDNEY 

products  of  the  body — those  most  actively  poisonous  to  the 
tissues,  and  the  excretion  of  which  is  dependent  largely  on  a 
healthy  condition  of  the  renal  tissue.  Hence  is  those  diseases  of  the 
kidney  chiefly  characterized  by  toxic  symptoms,  or  in  which  auto- 
toxemia  plays  an  important  primary  or  symptomatic  part,  that  the 
activity  of  these  tubules  is  found  defective.  Although  the  question 
of  blood  pressure  also  enters  largely  into  the  functional  require- 
ments of  these  tubes,  their  activity  is  chiefly  dependent  on  the 
primary  action  of  the  tubular  epithelial  cells. 

Notwithstanding  the  fact  that  the  renal  epithelium  has  a  sepa- 
rate nerve  supply  (Berkeley),  the  chief  nervous  control  of  the 
kidney  is  supplied  through  fibers  distributed  to  the  vessels.  The 
influence  of  central  nervous  control  on  the  renal  function  is  too  well 
known  to  require  a  detailed  discussion  here. 

Although  the  possibility  of  the  existence  of  an  internal  renal 
secretion  cannot  be  disproved,  the  chief  function  of  the  kidney 
is  the  excretion  of  urine;  this,  as  previously  stated,  is  a  very 
complex  process. 

The  quantity  of  urine  voided  is  dependent  primarily  on  the 
amount  of  water  taken  with  the  food  or  as  drink,  and,  secondarily, 
on  the  quantity  of  fluid  excreted  by  other  organs,  such  as  the 
bowel  or  by  the  skin.  Ordinarily,  the  amount  varies  between 
1200  c.c.  and  1800  c.c.  daily,  though  it  may  be  much  smaller, 
as,  for  instance,  in  profuse  diaphoresis;  or,  on  the  other  hand,  it 
may  exceed  this  amount,  as,  for  example,  when  large  quantities 
of  water  or  other  fluids  are  taken. 

Experiments  carried  on  by  means  of  catheterization  of  the 
ureters  show  that  in  normal  kidneys,  provided  the  size  is  the 
same,  each  kidney  secretes  in  a  given  space  of  time  almost  exactly 
the  same  amount  of  urine,  although  they  do  not  necessarily  act 
synchronously.  The  amount  of  fluid  and  of  solid  constituents 
from  each  kidney  separately  will  not  vary  much  over  10  per 
cent. 

The  Urine. — Immediately  after  being  passed,  and  while  still  at 
the  temperature  of  the  body,  the  urine  should  be  perfectly  clear, 
a  turbidity  at  this  time  indicating  some  unnatural  or  diseased 
condition;  on  being  allowed  to  stand,  however,  a  precipitate 
may  form,   when,   after  cooling,   elements  may  be  precipitated 


PHYSIOLOGY 


157 


out  that  are  not  abnormal  to  the  urine;  or,  on  undergoing  fer- 
mentation, the  chemic  characters  may  be  altogether  altered, 
causing  the  precipitation  of  various  substances,  such  as  the  alka- 
line phosphates. 

Normally,  the  color  of  the  urine  is  some  shade  of  yellow, — 
"straw  color," — the  degree  of  pigmentation  being  dependent  on 
many  conditions,  and  varying  greatly  not  only  in  intensity,  but 
also  in  color.  The  degree  of  pigmentation  is  due  to  the  presence 
of  four  substances — urochrome,  urobilin,  uroerythrin,  and  hemato- 
porphyrin — which  are  chiefly  derivatives  of  the  blood  and  bile. 

Normal  urine  is  acid  in  reaction,  the  acidity  being  due  to  an 
excess  of  diacid  sodium  phosphate.  The  reaction  fluctuates 
considerably  under  normal  conditions,  being  largely  dependent 
on  the  food  ingested  and  on  the  amount  of  the  urinary  fluid. 

The  specific  gravity  of  normal  urine  varies  greatly  under  many 
physiologic  as  well  as  pathologic  conditions.  It  is  dependent  in 
large  measure  on  the  relative  amount  of  liquids  and  solids  ingested. 
Roughly,  it  may  be  said  normally  to  fluctuate  between  1.012  and 
1.025. 

The  normal  chemic  composition  of  the  urine  is  dependent, 
naturally,  on  the  nature  and  amount  of  food  and  drink  taken, 
on  the  action  of  the  tissues  of  the  body  under  normal  or  abnormal 
conditions,  and  on  the  amount  of  tissue-waste. 

Bunge  gives  the  following  tables,  based  on  a  diet  of  beef  with 
salt  and  water,  and  on  a  diet  of  bread,  butter,  and  water,  com- 
puted as  the  result  of  an  analysis  of  the  total  twenty-four-hour 
urine  of  a  healthy  young  man : 


Meat  Diet. 
c.c 
gm. 


Total  amount 1672 

Urea .  .67.2 

Creatinin 2.163 

Uric  acid 1.398 

Sulphuric  acid  (total) 4.674 

Phosphoric  acid 3.437 

Calcium 0.328 

Magnesium 0.294 

Potassium 3.308 

Sodium 3.391 

Chlorin 3.817 


Bread  Diet. 

1920    c.c. 
20.3       gm. 

0.961 

9.253 

1.265 

1.658 

0.339 

0.139 

1.314 

3.923 

4.996 


158  THE    KIDNEY 

Urea,  the  most  important  organic  salt  of  the  urine,  is  the 
end-product  of  the  decomposition  of  the  albuminoids  of  the  food 
and  of  the  proteid  metabolism  of  the  body.  It  exists  in  the  bloody 
is  not  a  renal  product,  and  its  only  relation  to  the  kidney  seems 
to  be  that  it  is  normally  excreted  in  greater  part  by  this  gland. 
The  amount  of  urea  found  in  the  urine,  minus  that  derived  from 
the  decomposition  of  the  albuminous  portions  of  the  absorbed  food, 
may  be  taken  as  a  measure  of  the  proteid  metabolic  waste  of  the 
body.  The  amount  of  urea  is  increased  particularly  in  the  acute 
febrile  diseases  and  in  diabetes.  It  is  often  entirely  absent  in 
acute  yellow  atrophy  of  the  liver,  where  it  is  represented  by  less 
highly  oxidized  bodies,  as  leucin  and  tyrosin.  (Concerning  the 
chemistry  of  urea,  the  reader  is  referred  to  works  on  physiologic 
chemistry.) 

The  determination  of  the  amount  of  urea  present  in  the  urine 
is  often  very  important  in  clinical  medicine.  In  determining  this, 
however,  as  pointed  out  by  Cabot,  insufficient  attention  is  often 
paid  to  the  amount  of  albuminous  food  taken  in  as  compared 
with  the  amoimt  excreted. 

Uric  acid  is  formed  as  the  result  of  the  decomposition  of  the 
nucleins  either  of  the  food  or  of  the  body-tissues.  It  is  formed 
in  most  of  the  organs  of  the  body.  It  appears  normally  in  the 
urine  in  small  quantities,  being  derived  chiefly,  according  to 
Horbaczewski,  from  the  nuclei  of  the  leukocytes.  In  man  the 
uric  acid  derived  from  the  purin  substances  is  largely  transformed 
into  the  more  soluble  urea;  the  amount  excreted,  therefore,  also 
depends  partly  on  the  extent  to  which  this  oxidation  takes  place. 

COMPENSATION  IN  RENAL  DISEASE 
Although  the  kidney  is  the  chief  excretory  organ  of  the  body, 
its  relationship  and  connection  with  certain  other  excretory 
organs  have  been  well  established.  This  is  particularly  true  as 
regards  the  skin  and  the  intestine,  it  being  well  known  that  these 
may  take  on  the  renal  functions,  at  least  to  a  limited  degree, 
when  the  function  of  the  kidney  becomes  impaired.  In  man  and 
the  higher  mammals  it  seems  probable  that  the  other  excretory 
organs  cannot  assume  the  renal  function  completely,  though  in 
certain  of  the  lower  forms  of  animals  this  seems  to  be  possible. 


COMPENSATION    IN   RENAL   DISEASE  1 59 

It  has  been  shown  that  bilateral  nephrectomy,  ligation  of  both 
ureters,  or,  in  other  words,  total  annihilation  of  the  renal  func- 
tion, results  in  death  in  from  seven  to  fourteen  days  (Martin), 
notwithstanding  the  fact  that  the  other  excretory  organs  have 
reached  their  highest  degree  of  activity.  Northrup  reports  an 
undoubted  case  of  total  suppression  of  the  urine  lasting  for  five 
days,  but  followed  by  resumption  of  excretion  and  recovery.^ 

Conversely,  the  kidney  may  assume  the  function  of  the  other 
excretory  organs;  this  takes  place  not  only  in  disease,  but  also 
in  certain  physiologic  states.  Thus  in  cold  weather  when  the 
superficial  capillaries  are  contracted  and  the  excretion  of  water 
in  the  form  of  sweat  is  diminished,  urinary  excretion  is  markedly 
augmented;  on  the  other  hand,  during  hot  weather,  when  the 
perspiration  is  abtmdant,  the  urine  is  excreted  in  small  amounts; 
this  takes  place  also  in  diarrhea,  when  the  amount  of  water  dis- 
charged by  the  bow^el  is  great.  These  facts  are  often  taken  advan- 
tage of  in  the  treatment  of  renal,  intestinal,  and  dermal  affections. 
Thus  in  severe  constipation,  intestinal  obstruction,  or  in  other 
conditions  when  the  bowel  is  no  longer  able  fully  to  carry  on  its 
function,  the  kidney  may,  to  a  certain  degree,  temporarily  assume 
some  of  the  activities  of  the  affected  organ.  Clinically,  W'hen  the 
above-mentioned  conditions  exist,  it  is  well  to  maintain  the  renal 
activity  at  its  highest  point;  at  the  same  time  every  possible 
care  must  be  exercised  to  guard  against  overactivity  lest  the 
function  of  the  renal  organs  become  impaired  and  suppression  of 
the  urinarv  secretion  follow. 

In  cases  of  grave  nephritic  disease  the  bowel  also  casts  off, 
although  perhaps  incompletely,  certain  of  the  substances  that 
would  normally  be  thrown  off  by  the  kidney;  in  nearly  all  forms 
of  renal  disorder,  therefore,  it  is  particularly  necessary  to  see  that 
the  excretory  functions  of  the  bowel  and  skin  be  maintained  at 
their  highest  point  of  efficiency.  In  spite  of  this  close  interde- 
pendence of  function  it  is  doubtless  true  that  when  one  organ  does 
not  act  in  a  normal  manner,  poisons  are  thrown  into  the  blood 
and  lymph  that  may  produce  most  serious  disease  of  the  functionat- 
ing parenchyma  of  the  other ;  thus,  for  example,  in  intestinal  ob- 

1  Transactions  of  the  Association  of  American  Physicians,  1910. 


l6o  THE    KIDNEY 

struction,  in  toxic  dysentery,  and  in  other  similar  conditions  grave 
nephritic  compHcations  are  particularly  likely  to  occur. 

A  remarkable  fact,  in  this  connection,  is  that,  occasionally, 
in  spite  of  extensive  disease  of  the  kidney,  resulting  in  some  cases 
in  almost  complete  destruction  of  the  parenchyma,  the  patient 
may  continue  to  live  in  apparent  health.  This  is  well  exemplified 
in  congenital  cystic  kidney,  when,  as  in  the  case  illustrated  in 
fig.  88,  apparently  the  entire  normal  renal  tissue  may  be  absent 
and  yet  life  continue  until  an  intercurrent  affection  arises  that 
may  unbalance  the  well-compensated  excretion  carried  on,  for 
the  most  part,  by  the  bowel  apd  skin.  Perhaps  one  of  the  most 
familiar  illustrations  of  this  is  seen  in  cases  of  severe  chronic  inter- 
stitial nephritis,  in  which  the  urine  secreted  by  the  extensively 
diseased  kidneys  differs  from  normal  urine  in  so  far  that  the  waste- 
products  of  cell-metabolism  are  largely  absent.  Undoubtedly, 
in  some  of  these  cases,  a  too  unfavorable  prognosis  is  given;  this 
would  be  modified  somewhat  if,  in  each  particular  instance,  the 
compensatory  action  of  the  other  excretory  viscera  was  thoroughly 
considered. 

In  contradistinction  to  what  has  been  said,  it  is  surprising  what 
minute  renal  lesions  may  result  in  speedy  death.  This  is  most 
likely  to  occur  in  acute  cases,  as,  for  example,  in  acute  eclampsia, 
where  the  subsidiary  organs  are  unprepared  to  take  on  compensa- 
tory action ;  in  these  cases  the  efforts  should  be  directed  toward 
establishing  compensatory  action  by  other  excretory  organs,  rather 
than  toward  stimulating  an  already  overworked  and  extensively 
diseased  kidney. 

When,  because  of  disease  of  the  other  excretory  organs,  the  kid- 
ney is  suddenly  called  upon  to  assume  compensatory  activity,  it 
may  be  unprepared  to  respond  to  the  demand  and  acute  nephritis 
and  uremia  may  follow  as  a  consequence.  This  is  probably  best 
illustrated  by  those  cases  in  which  the  secretion  of  sweat  is  sud- 
denly arrested,  as  when  the  surface  of  the  body  has  been  quicklv 
chilled,  by  the  familiar  example  of  the  boy  who  was  coated  with 
gold-leaf,  or,  as  has  been  personally  observed,  after  early  or  too  pro- 
longed sea-bathing.  As  a  frequent  illustration  may  also  be  cited 
cases  of  extensive  burns,  where  large  areas  of  skin  have  been  in- 
jured or  destroyed,  death  usually  following  from  acute  nephritis. 


COMPENSATION   IN    RENAL    DISEASE  l6l 

In  these  cases  the  development  of  renal  lesions  is  not  dependent 
so  much  on  the  degree  of  severity  of  the  burns  as  on  their  extent, 
this  latter  affecting  the  amount  of  sporadic  activity  suddenly 
demanded  of  the  renal  tissues.  Death  caused  by  nephritis  follow- 
ing but  limited  burns  is  probably  not  uncommonly  due  to  a  pre- 
viously impaired  renal  activity.  That  this  failure  on  the  part  of 
the  kidneys  to  respond  is  due  to  the  abruptness  of  the  demand 
is  well  illustrated  by  the  fact  that  nephritis  with  fatal  termination 
does  not  generally  occur  when  the  excretory  powers  of  the  skin 
or  bowel  are  slowly  obtunded,  as  in  stricture  of  the  bowel  result- 
ing from  gradual  occlusion  due  to  peritoneal  or  neoplastic  adhe- 
sions; nor  from  suppression  of  the  dermal  excretion  in  morphea 
or  scleroderma  when  the  excretory  functions  of  the  skin  are  slowly 
obliterated.  In  short,  it  would  appear  that  the  kidney  must  be 
given  time  to  accommodate  itself  to  the  increased  demands  upon 
its  functional  capacity.  This  is  a  most  important  fact  to  be  borne 
in  mind  in  considering  the  treatment  of  these  conditions,  it  being 
evident  that  certain  changes  must  take  place  in  the  organ  before 
it  is  able  thus  vicariously  to  functionate. 

As  has  been  stated,  the  size  of  the  normal  kidney  is  propor- 
tionate to  the  body  weight;  the  larger  the  man,  therefore,  the 
greater  the  amount  of  renal  tissue  necessary  to  carry  on  the  excre- 
tory process.  From  this  it  would  appear  that  there  is  a  certain 
definite  relation  between  kidney  bulk  and  kidney  function,  and 
it  may  be  assumed  that  when  increased  function  is  demanded  of 
the  organ,  an  increase  in  the  parenchymatous  epithelium  takes 
place.  That  this  occurs  has  been  abundantly  proved  by  studies 
in  pathologic  anatomy  and  in  experimental  pathology. 

Compensatory  hyperplasia  of  the  kidney  may  take  place  in  the 
fetus ;  for  if,  because  of  some  defect,  the  anlage  for  one  kidney  is 
insufficiently  nourished,  the  other  organ  will  show  a  compensa- 
tory hyperplasia  of  the  epithelium.  This  is  well  exemplified 
by  those  cases  in  which  but  a  single  kidney  exists,  the  one  organ 
being  found  to  bear  approximately  the  relative  weight  to  the 
body  that  the  two  kidneys  bear  in  normal  cases.  Compensatory 
hyperplasia  is  by  no  means  limited  to  the  fetal  condition.  When 
it  becomes  necessary,  therefore,  to  remove  one  kidney,  the  re- 
maining organ,  if  healthy,  may  be  expected  to  show  an  increase 


l62  THE    KIDNEY 

in  its  parenchyma  and  eventually  to  carry  on  the  entire  renal 
function  in  a  satisfactory  manner.  In  a  young  and  healthy 
subject  the  remaining  organ  will  eventually  attain  a  weight  equal 
to  that  normal  for  the  two  kidneys.  From  what  has  been  said  it 
is  clear  that  a  certain  length  of  time  is  necessarily  required  to 
effect  epithelial  hyperplasia,  and  in  these  cases  it  is  essential  that 
means  be  devised  for  facilitating  compensatory  excretion  on  the 
part  of  other  organs  until  sufficient  time  has  elapsed  for  the  neces- 
sary epithelial  growth  to  take  place.  This  epithelial  hyperplasia 
undoubtedly  occurs  in  most  of  the  compensatory  conditions  that 
have  been  considered.  If  sufficient  time  has  not  elapsed  for 
this  to  take  place,  the  organ  is  suddenly  overwhelmed  with  poison- 
ous waste-materials,  which  it  is  unable  to  handle,  and  which,  con- 
sequently, act  on  the  renal  cells  as  cytotoxins. 

Compensatory  hyperplasia  is  a  process  that  is  not  limited  to 
any  particular  portion  of  the  cortex.  For  instance,  if  infarction 
destroys  a  portion  of  the  cortex  of  one  kidney,  compensatory 
hyperplasia  may  take  place  in  the  opposite  organ  or  in  other  por- 
tions of  the  cortex  of  the  injured  viscus.  The  degree  of  hyper- 
plasia varies  greatly.  In  heahng  scarlatinal  nephritis,  where 
extensive  desquamation  of  tubular  epithelium  has  taken  place, 
the  process  may  consist  merely  of  replacement  of  the  diseased  cells 
by  newly  formed  ones  on  the  old  basement  membrane;  or,  on 
the  other  hand,  the  actual  formation  of  new  tubes  may  occur. 
This  latter  fact  has  been  disputed  by  some  observers,  but  has  been 
thoroughly  substantiated  by  experimental  work. 

Naturally,  compensatory  hyperplasia  is  most  likely  to  take 
place  during  youth  and  when  the  kidneys  themselves  are  in  a 
comparatively  normal  condition;  nevertheless,  it  often  occurs 
in  old  age  and  in  diseased  conditions  where  it  is  least  expected. 
Hyperplasia  is,  of  course,  limited  largely  to  the  parenchyma  and 
chiefly  to  the  cortex.  It  is  most  unlikely  to  occur  when  pro- 
nounced interstitial  alterations  have  occurred.  It  is  the  essential 
change  in  nearly  all  healing  processes  that  follow  any  of  the  types 
of  nephritis,  and  the  process  is  undoubtedly  accelerated  by  the 
various  methods  shown  by  experience  to  be  valuable  in  the  treat- 
ment of  patients  convalescent  from  renal  disorders. 


CHAPTER  VI 

THE  BLOOD   IN  DISEASES  OF  THE  KIDNEY 

Revolutionary  advances  have  been  made  within  the  past  few 
years  in  the  study  of  blood  in  diseases  of  the  kidney.  These  re- 
searches have  done  more  to  direct  the  modem  concept  and  clin- 
ical study  of  renal  disease  than  any  other  single  factor  since  clinical 
study  of  the  urine  became  general.  Not  only  have  these  studies 
served  to  lead  us  to  a  new  and  eminently  practical  viewpoint  of 
the  blood  changes  in  renal  disease,  but  they  have  also  thrown  much 
light  on  the  physiology  of  the  kidney,  and  at  this  time  they  appear 
to  fm-nish  us  with  accm-ate  data  on  which  to  base  prognosis  in 
several  types  of  renal  disease. 

Unfortunately  as  yet  the  blood  changes  which  occur  in  kidney 
defects  have  not,  as  Ewing  criticizes,  been  coupled  up  and  identified 
with  certain  pathologic  changes.  There  can,  however,  be  no  doubt 
but  that  in  the  near  future  this  side  of  the  picttu"e  will  also  be  placed 
on  a  certain  basis,  and  it  is  quite  possible  that  we  shall  then  be  in  a 
position  to  satisfactorily  classify,  prognose,  and  treat  kidney  dis- 
ease, a  point  from  which  we  are  as  yet  widely  removed. 

These  studies  are  chiefly  chemical  in  natm-e,  and  while  from  the 
viewpoint  of  the  expert  chemist  they  present  no  particularly  diffi- 
cult problem,  the  methods  are  not  as  yet  such  as  may  be  applied 
by  the  ordinary  clinician,  although  their  application  is  so  simple  and 
direct  that  without  an  intimate  knowledge  of  chemical  technic 
they  may  be  fully  comprehended  and  used  by  any  serious  clinical 
student.  We  shall,  therefore,  make  an  attempt  to  discuss  this 
matter  from  the  stand  of  the  technical  chemist,  and  the  reader  is 
referred  to  the  numerous  researches  published  in  every  journal 
devoted  to  this  branch  of  medical  work  for  technical  considerations. 
Suffice  it  to  say  that  the  amount  of  blood  required  is  astonishingly 
small,  lo  or  15  c.c.  being  ample  for  nearly  all  necessary  studies  for 
clinical  purposes. 

In  general,  it  is  advisable  or  necessary  to  conduct  these  studies 

163 


l64  THE   BLOOD    IN   DISEASES    OF    THE    KIDNEY 

comparatively  with  accurate  quantitative  studies  of  the  urine, 
and  since  it  has  been  shown  that  the  diet  very  directly  effects  the 
character  of  the  blood  in  both  health  and  disease,  it  is  necessary 
also  for  proper  judgment  to  know  at  least  approximately  the 
amount  of  the  various  food  elements  which  enter  into  the  diet  of 
any  patient  under  question.  This  may  be  very  simply  effected 
by  placing  the  patient  upon  a  milk  diet  of  known  amount,  though 
it  is  advisable  to  know  also  the  amount  of  salts  and  ash  intake. 
Obviously  the  fluid  intake  is  of  very  elemental  importance,  and 
whether  or  not  edema  is  present  and  its  degree  has  also  great 
import. 

Studies  in  renal  permeability  have  shown  without  apparent 
exception  that  where  permeability  is  diminished  the  blood  in- 
variably shows  changes  indicating  a  storing  up  in  the  blood  of 
materials  which  in  physiologic  states  are  excreted  by  the  kidney. 
This  particularly,  and  quite  in  accord  with  our  previous  concept  of 
renal  disease,  applies  to  the  nitrogenous  elements. 

In  most  if  not  in. all  types  of  renal  defects  this  condition  is 
often  indicated  by  a  retention  of  nitrogen  within  the  body  fluids 
and  notably  in  the  blopd.  This  nitrogen  appears  in  the  form  of 
filterable  nitrogen,  and  the  amount  of  nitrogen  thus  retained  in  the 
blood  may  total  up  to  as  much  as  four  to  seven  times  that  normally 
present.  On  a  known  diet,  with  a  determined  quantitative  urinary 
study,  the  amount  of  retained  nitrogen  may,  in  our  opinion,  be 
fairly  taken  as  an  indication  of  the  severity  of  the  renal  defect,  and 
it  is  in  high  degree  of  prognostic  value.  For  our  own  clinical  studies 
we  have  in  most  cases  been  content  to  determine  this  total  amount 
of  retained  nitrogen,  but  some  clinicians  prefer  to  further  amplify 
this  by  a  nitrogen  partition  in  which  the  various  forms  of  retained 
nitrogen  are  relatively  determined  and  considered.  Certain 
students  thus  believe  that  the  amount  of  creatinin  retained  within 
the  blood  is  the  most  important  element,  others  that  the  blood  urea 
is  the  most  certain  measure  of  the  degree  of  renal  incompetence. 
Halsey,  Chase,  and  others  associated  with  them  believe  that  the 
earliest  blood  evidence  of  beginning  kidney  disease  is  the  retention 
of  uric  acid  in  abnormal  and  increasing  amounts  in  the  blood. 
If  this  be  true  it  may  seem  that  there  is  a  close  relationship  between 
gout  and  early  renal  disease.      From  our  personal  study,  con- 


The;  blood  in  diseases  of  the  kidney  165 

ducted  mostly  in  regard  to  gout  primarily,  we  are  unable  to  cor- 
roborate this  supposition. 

While  there  can  be  no  question  whatever  but  that  much  is  yet 
to  be  learned  from  close  study  by  nitrogen  partition  methods,  we 
are  of  the  opinion  that  for  clinical  purposes,  and  taking  into  con- 
sideration the  time  and  expense  necessary  for  the  more  elaborate 
determinations,  the  simple  determination  of  the  total  retained 
filterable  nitrogen  is  quite  sufficient. 

Less  study  has  thus  far  been  reported  concerning  the  variation  in 
the  salt  content  in  the  blood  in  the  various  forms  of  renal  inade- 
quacy, but  we  are  all  convinced  that  as  the  technic  of  the  subject 
becomes  perfected  and  simplified  that  much  very  direct  and  valu- 
able evidence  will  be  furnished  in  many,  if  not  in  all,  cases  of  kidney 
disease.  This  is  probably  particularly  true  of  quantitative  studies 
of  NaCl.  We  know  that  particularly  in  kidney  disease  in  which 
the  glomerulus  is  obHterated  by  fibrous  growth  the  excretion  of 
sodium  chlorid  is  particularly  hindered,  and  this  doubtless  con- 
tributes very  largely  to  edema  in  those  instances  of  nephritis  where 
this  appears  as  an  important  symptom.  We  have  noted  in  several 
cases  that  although  the  excretion  of  NaCl  by  the  urine  was  greatly 
diminished,  and  the  giving  of  this  drug  failed  to  cause  a  raise  in  the 
concentration  of  the  urine  in  this  respect,  yet  salt  was  not  found  in 
increased  amounts  in  the  blood  as  appears  to  be  usually  the  case, 
but  that  the  chemical  appeared  to  be  bound  either  in  the  muscles 
and  subcutaneous  tissues  or  in  the  edematous  fluid  itself. 

Though  we  are  completely  convinced  of  the  great  value  and  im- 
portance of  these  blood  studies  in  cases  of  clinical  renal  disease,  and 
though  we  believe  that  they  offer  diagnostic  and  prognostic  data 
to  be  obtained  in  no  other  way,  physicans  are  cautioned  not  to  ac- 
cept as  final  and  conclusive  such  data  as  compared  to  the  facts 
which  appear  when  every  aspect  of  the  case  is  considered  from  the 
clinical  standpoint.  Cases  have  been  under  our  observation  which 
died  and  were  proved  by  autopsy  to  have  been  bonafide  instances 
of  interstitial  nephritis  in  which  nonetheless  absolutely  no  blood  in- 
dications of  the  renal  disease  could  be  shown,  and  we  have  also  had 
cases  in  which  the  blood  findings  indicated  the  most  serious  and 
rapidly  fatal  possible  type  of  kidney  disease  apparently,  and  yet 
which  survived  for  long  periods  of  time.     We  have  in  this  method  a 


1 66  THE   BLOOD    IN   DISEASES   OF    THE    KIDNEY 

most  valuable  and  hopeful  addition  to  our  methods  of  study  of 
kidney  disease,  but,  like  most  things  in  medicine,  it  is  by  no  means 
certain  or  infallible,  and  while  it  adds  to,  it  in  no  essential  way 
displaces,  the  older  methods  of  clinical  observation.  As  an  out- 
growth of  these  studies,  particularly  when  conducted  in  associa- 
tion with  careful  urinary  studies,  computations  of  the  blood-press- 
ure, etc.,  numerous  so-called  tests  or  ratios  have  been  worked  out, 
the  so-called  color  reaction  of  Larkin  and  Lewy,  the  Ambard  index, 
and  others  which  are  supposed  to  give  certain  knowledge  as  to  the 
outcome  or  actual  status  of  any  case.  We,  like  most  others,  have 
had  periods  of  great  faith  in  this  or  that  test,  but  as  our  experience 
has  multiplied  this  has  given  way  to  only  a  more  firm  reliance  on 
the  value  of  the  clinical  picture  of  each  individual  case,  taken  as  a 
problem  by  itself. 

Microscopic  examination  of  the  blood  is  valuable  in  the  diagnosis 
of  kidney  diseases  only  to  a  very  limited  degree.  Unquestion- 
ably, its  greatest  diagnostic  usefulness  is  in  suspected  renal  sup- 
puration. 

Polynuclear  leukocytosis  is  generally  concomitant  with  suppura- 
tive diseases  of  the  kidney,  except  when  the  drainage  from  the 
suppurative  focus  is  free;  it  has  then  been  found,  as  a  rule,  that 
leukocytosis,  at  least  in  marked  degree,  is  often  absent.  In  these 
instances,  when  pus  escapes  freely,  the  question  as  to  the  pres- 
ence or  absence  of  suppuration  can  be  readily  settled  since  pus 
is  found  in  the  urine  or  escaping  through  a  fistulous  opening. 
When  the  pus  does  not  escape,  the  polynuclear  leukocytes  are 
commonly  increased,  the  degree  of  leukocytosis  depending,  in 
the  writers'  experience,  on  the  extent  and  virulence  of  the  puru- 
lent process.  As  exceptions  to  this  general  rule  may  be  cited 
the  absence  of  leukocytosis  in  old  and  well-localized  pus-forma- 
tions, also  in  those  rarer  instances  where  the  infective  process  is 
so  overwhelming  that  the  production  of  leukocytosis  seems  to  be 
inhibited.  In  suppurative  disease  localized  to  the  kidneys  the 
number  of  leukocytes  rarely  exceeds  20,000,  and  is  more  often  in 
the  neighborhood  of  from  12,000  to  15,000. 

In  tubercular  nephritis,  as  a  rule,  the  leukocytes  are  not  increased 
unless  the  tubercular  process  is  complicated  by  a  mixed  infection 
with  other  pyogenic  bacteria.     On  the  contrary,  hypoleukocy- 


THE  BLOOD  IN  DISEASES   OF   THE  KIDNEY  1 67 

tosis  may  be  present,  and  a  differential  count  of  the  leukocytes 
may  show  a  relative  increase  in  the  mononuclear  elements,  al- 
though not  so  regularly  as  in  general  tubercular  disease. 

In  new-growths  of  the  kidneys  the  blood  shows  the  same  general 
characteristics  seen  in  new- growths  elsewhere,  but  the  cachectic 
type  of  anemia  may  serve,  in  a  certain  number  of  cases,  to  distin- 
guish renal  growths  from  abscesses  or  non-neoplastic  hypertrophy. 

Nephritis  furnishes  some  of  the  most  important  blood-picture 
changes  in  renal  disease,  such  changes  occurring,  of  course,  second- 
arily; in  pernicious  and  other  severe  anemias,  however,  nephritis 
itself  often  arises  as  a  secondary  condition. 

In  acute  nephritis  an  anemia  occurs  that  is  usually  characterized 
by  a  proportionate  reduction  in  hemoglobin  and  red  cells.  It 
is  commonly  believed  to  be  due  directly  to  the  loss  of  blood  with 
the  urine,  but  it  is  often  too  marked  in  degree  to  be  accounted 
for  on  this  basis  alone ;  besides,  it  develops  in  some  cases  in  which 
no  loss  of  blood  can  be  demonstrated.  Leukoc3rtosis  with  a 
count  of  20,000  has  been  noted  by  some  observers  (Cabot),  but, 
in  the  writers'  experience,  it  is  not  constant  or  sufficiently  fre- 
quent to  render  it  of  diagnostic  value.  It  is  probable,  at  least 
in  a  certain  number  of  cases,  that  this  leukocytosis  is  a  relative 
one  only,  and  due  to  loss  of  the  red  corpuscles. 

When  edema  of  considerable  degree  is  present,  hydremia  may 
often  be  found  a  symptom  of  much  importance.  Although,  as  a 
rule,  the  coagulabiUty  of  the  blood  is  not  altered  in  markedly 
hydremic  cases,  it  may  be  markedly  decreased ;  at  the  same  time, 
when  the  loss  of  blood  from  renal  hemorrhage  has  been  consider- 
able, coagulability  may  be  increased. 

The  alkalinity  of  the  blood  sometimes  falls  below  normal; 
in  the  acute  diseases,  as  a  rule,  it  has  been  found  to  be  unaffected. 

In  subacute  or  chronic  parenchymatous  nephritis,  when  the  par- 
enchyma of  the  kidneys  is  chiefly  affected,  the  most  characteristic 
forms  of  anemia  develop.  In  certain  cases,  however,  the  anemic 
condition  is  more  apparent  than  real,  and  pallor  of  the  skin  and 
mucosae  may  be  found  associated  with  practically  normal  blood- 
findings.  It  is  quite  probable,  in  at  least  some  of  these  cases,  that 
though  the  blood  itself  is  normal  in  its  commonly  recognized  char- 
acteristics, there  is  an  inability  on  the  part  of  the  tissues  to  take 


l68  THE   BLOOD    IN   DISEASES    OF    THE    KIDNEY 

Up  the  requisite  amount  of  oxygen   and   nourishment  from  the 
circulating  stream. 

The  hemoglobin  is  markedly  reduced,  occasionally  falling  as 
low  as  from  30  to  40  per  cent.,  whereas  the  number  of  red  cor- 
puscles, though  generally  somewhat  lowered,  is  proportionately 
less  so.  This  gives  a  blood-picture  not  unlike  that  of  chlorosis, 
a  disease  that  is  frequently  confused  with  nephritis,  and,  when 
the  examination  is  not  thorough,  nephritis  is  often  mistaken 
for  chlorosis. 

As  a  rule,  in  those  cases,  the  leukocytes  are  somewhat  increased 
relatively,  though  they  rarely  exceed  from  10,000  to  12,000,  and 
a  differential  count  estabhshes  the  fact  that  the  relative  percentage 
is  normal,  thus  differentiating  this  condition  from  one  of  absolute 
leukocytosis. 

The  alkahnity  of  the  blood  is  generally  somewhat  reduced; 
this  is  quite  a  constant  finding  in  this  type  of  nephritis.  As  in 
the  acute  form  of  the  disease,  coagulability  may  be  lowered. 

Anemia  often  becomes  a  matter  of  grave  significance  in 
nephritis  of  this  form,  and  its  treatment  is  of  the  utmost  im- 
portance. There  can  be  no  doubt,  in  a  certain  number  of  cases 
at  least,  that  the  dietetic  restrictions  that  form  part  of  the  treat- 
ment of  the  renal  condition  are  in  some  measure  responsible  for 
the  anemia,  and  this  fact  must  be  held  in  consideration. 

In  chronic  interstitial  nephritis  the  blood,  as  a  rule,  shows  no  mi- 
croscopic variations  that  are  directly  attributable  to  the  renal  dis- 
ease. When  the  circulation  has  become  slowed,  as  in  certain  of  the 
circulatory  and  cardiac  manifestations  of  nephritis  of  this  type,  the 
hemoglobin  percentage  and  the  red-cell  count  may  even  be  in- 
creased and  a  true  oligocythemia  develop.  In  these  cases,  natu- 
rally, if  secondary  conditions  play  an  important  role,  as  when  epis- 
taxis  is  frequent,  anemia  may  develop  secondarily.  When  due  to 
other  and  perhaps  primary  conditions,  anemia  may  also  produce 
an  entirelv  different  blood-picture.  Thus  in  the  chronic  intersti- 
tial nephritis  that  occurs  in  lead-poisoning  a  profound  anemia 
is  a  prominent  symptom;  occasionally  it  simulates  a  primary 
anemia,  and  is  generally  evinced  by  marked  granular  degenerative 
alterations  in  the  red  cells. 

In  uremia  the  blood  may  show  any  of  the  changes  associated 


THE   BLOOD   IN   DISEASES   OF    THE   KIDNEY  169 

with  the  special  type  of  nephritis  that  is  present,  but  an  almost  con- 
stant manifestation  is  a  marked  reduction  in  alkalinity,  falling 
rapidly  as  the  case  becomes  more  grave  and  increasing  as  the 
uremic  symptoms  disappear.  The  leukocytes  are  also  rather 
constantly  increased  in  uremia  (Ewing).  Pieraccini  has  found 
that  the  number  of  eosinophile  leukocytes  is  considerably  dimin- 
ished in  uremia,  this  diminution  corresponding  to  the  severity 
of  the  case  and  to  the  decrease  preceding  the  development  of 
uremic  symptoms;  its  occurrence,  therefore,  may  be  regarded  as 
a  symptom  of  some  prognostic  value. 

The  treatment  of  hemic  disturbances  arising  in  the  course  of 
renal  disease  practically  resolves  itself  into  a  treatment  of  the 
nephritic  anemia.  The  course  pursued  in  similar  conditions 
arising  independently  or  occurring  during  the  progress  of  many 
other  diseases  must  be  considerably  modified  in  nephritis.  This 
is  particularly  true  of  dietetic  measures,  for  the  food  that  is 
indicated  in  other  types  of  anemia  must,  because  of  its  delete- 
rious action  on  the  kidney,  be  forbidden  in  nephritis.  Thus 
it  may  be  necessary  to  limit  eggs,  beef -juice,  and  foods  of  a  similar 
nature.  Lemonade  and  milk,  which  act  very  beneficially  in  anemia 
generally,  may  be  employed  in  these  cases  with  actual  benefit  to 
the  renal  tissue  and  often  with  markedly  good  effects  on  the 
anemia.  The  same  applies  to  the  use  of  green  vegetables,  such  as 
spinach,  lettuce,  and  so  on.  The  outdoor  treatment  of  nephritic 
anemia  is  also  attended  with  excellent  results.  Patients  should  be 
encouraged  to  spend  as  much  time  as  possible  out-of-doors,  particu- 
larly in  the  sunshine;  and  suitable  exercise,  as  indicated  by  the 
existing  conditions,  should  be  prescribed. 

Like  the  anemia  of  chlorosis,  which  it  so  closely  simulates  in 
many  respects,  the  anemia  of  nephritis,  as  a  rule,  responds 
promptly  to  ferrous  medication.  In  most  cases  the  writers  have 
found  that  the  inorganic  preparations  of  iron  act  more  beneficially 
than  the  organic;  in  certain  cases,  however,  better  results  have 
been  attained  by  the  employment  of  organic  ferrous  compounds." 
The  two  preparations  that,  in  the  writers'  experience,  have  proved 
most  efficacious  have  been  the  tincture  of  the  chlorid  and  the 
familiar  "  Basham's  mixture,"  both  given  in  large  doses.  The  sul- 
phate or  carbonate,  or  the  combination  in  the  form  of  B laud's 


I  JO  THE   BLOOD   IN   DISEASES   OF   THE   KIDNEY 

pill,  also  acts  very  beneficially.  The  tartrate  of  iron  and  potash 
is  especially  efficient,  since  in  addition  to  its  ferruginous  qualities 
it  does  not  constipate.  In  other  respects  the  treatment  is  to  be 
directed  toward  the  underlying  nephritis. 

When  the  case  is  not  of  too  long  standing  and  is  uncomplicated 
by  other  diseases,  as  a  rule,  nephritic  anemia  responds  promptly 
to  well-directed  treatment.  Oftentimes  the  treatment,  though 
entirely  ferruginous  and  directed  to  the  correction  of  the  anemia, 
results  in  a  marked  improvement  in  the  general  renal  disturbance. 
This  has  been  found  to  be  particularly  true  of  those  cases  of 
nephritis  complicating  the  convalescence  from  the  infectious 
diseases.  As  a  result  of  iron  medication  albuminuria  tends  to 
disappear  more  rapidly,  edema  subsides,  and  the  general  vascular 
tone  improves  so  markedly  that,  in  some  cases  of  nephritis,  apart 
from  its  effect  on  the  anemia,  iron  seems  to  be  almost  a  specific. 

THE  BLOOD-PRESSURE  IN  RENAL  DISEASE 

That  there  is  an  increased  blood-pressure  in  many  types  of 
renal  disturbances  is  a  fact  that  has  long  been  recognized,  but  our 
knowledge  in  regard  to  the  constancy  of  its  occurrence  in  certain 
diseases  and  the  clinical  methods  devised  for  accurately  and 
easily  determining  its  existence  are  recent  acquisitions  to  this 
branch  of  study.  For  these  we  are  indebted  in  large  measure 
to  the  recent  admirable  contribution  of  T.  C.  Janeway,  "The 
Clinical  Study  of  Blood-pressure,"  where  this  imporant  manifes- 
tation has  been  most  completely  discussed  in  all  its  aspects. 
The  writers  have  found,  by  constant  routine  employment  of  the 
sphygmomanometer  for  the  past  years,  that  we  possess  in  this 
instrument  not  only  one  of  the  most  definite  and  constant  means 
of  diagnosing  obscure  cases  of  nephritis,  but  also  a  valuable 
aid  in  the  prognosis  of  renal  disease,  and  an  accurate  and  cer- 
tain method  of  determining  the  effects  of  treatment. 

For  clinical  purposes  the  instrument  known  as  the  Janeway, 
or  Kaplan's  modification  of  this  instrument,  is  to  be  recommended 
for  the  use  of  the  general  practitioner.  Of  the  other  instruments 
suitable  for  general  cHnical  use,  the  Riva-Rocci  has  given  the 
best  results  in  the  writers'  hands.     Recently  a  very  convenient 


THE   BLOOD-PRESSURE   IN   RENAL   DISEASE 


171 


instrument  has  been  designed  by  Dr.  O.  H.  Rogers.  The  pressure 
is  registered  by  a  circular  spring  dial,  virtually  an  aneroid.  Thus 
far  the  apparatus  has  proved  accurate  in  our  hands;  most  instru- 
ments depending  on  this   principle  have,  however,  not  proved 


Fig.  72. — The  Janeway  sphjg^momanometer. 


satisfactory  heretofore,  and  the  writers  usually  employ  for  work 
outside  the  office  and  hospital  the  compact  and  portable  instru- 
ment designed  by  Prof.  Sahli.  Where  accurate  graphic  records 
are  desirable  in  hospital  or  research  work  the  Erlanger  instru- 
ment doubtless  affords  the  greatest  range  of  possibility. 

Experience  has  corroborated  the  statements  made  by  Janeway 
and  the  other  observ^ers  quoted  by  him.  To  secure  accurate 
results  with  the  instrument,  a  certain  amount  of  practice  is  neces- 
sary, although  the  technic  essential  for  its  efficient  emplo^^ment 
is  readily  acquired.  In  order  to  obtain  accurate  results,  several 
determinations  should  be  made,  at  different  times  and  under 
varying  conditions,  as  with  the  patient  sitting,  standing,  or  lying 
down;    this,  particularly  with  a  view  to  avoiding  the  possibility 


172 


The  blood  in  diseases  of  the  kidney 


of  psychic  stimulation,  which  might,  in  some  cases,  lead  to  erro- 
neous conclusions. 

The  blood-pressure  cannot  be   satisfactorily  estimated  merely 
from  an  examination  of  the  pulse,  even  by  the  most  skilful  clinician. 


^  Blood-Pressnre  and  Pulse 
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-Bedside  chart,  showing  a  convenient  way  of  recording  blood-pressure 
pulse-rate.     P'rom  a  case  of  chronic  interstitial  nephritis. 


and 


Repeated  experiments  designed  to  demonstrate  the  value  of  this 
as  a  guide  to  ascertaining  the  amount  of  blood-pressure  have 
shown  that  but  little  rehance  is  to  be  placed  on  this  method  alone. 
The  estimates  of  most  reliable  clinicians  have  varied  from  the 
sphygmomanometric  determination  as  much  as  from  60  to  100 
mm.  of  mercury. 

In  acute  nephritis  the  blood-pressure  variations  are  marked. 
In  the  early  stages  of  the  disease  there  is  commonly,  and  often 
a  considerable,  increase,  but  there  may  be  a  decrease,  even  to  the 
subnormal,  particularly  when  cardiac  failure  is  imminent.  In 
the  nephritis  comphcating  the  acute  infections  experience  has 
shown  that  the  pressure  is  either  normal  or  subnormal,  and  that 
if  increased,  it  is  but  slightly  so.     In  these  conditions  the  deter- 


THE    BLOOD-PRESSURE    IN   RENAL   DISEASE  I73 

mination  of  the  blood-pressure  is  of  little  value  excepting  in  so  far 
as  it  may  be  used  to  differentiate  between  the  acute  exacerbation 
of  a  chronic  nephritis  and  an  acute  nephritis;  in  the  former  con- 
dition the  blood-pressure  is  constantly  high,  and  in  the  latter  it 
is  usually  but  little  altered,  although  occasional  acute  cases  are 
seen  in  which  the  pressure  is  as  high  as  in  chronic  cases. 

In  chronic  or  subacute  nephritis,  in  which  the  pachydermatous 
portions  of  the  kidney  chiefly  are  involved,  the  pressure  is,  as  a 
rule,  high,  although  in  the  writers'  experience  it  rarely  exceeds 
170  to  200  mm.  Hg°.  In  certain  cases,  however,  especialty  when 
there  is  a  loss  of  vascular  tone,  as  in  myocarditis  or  disease  of 
the  arterial  media,  the  pressure  may  be  below  normal,  reaching 
as  low  as  85  mm.  Hg°  (systoUc  pressure).  In  those  forms  of  renal 
disease  in  which  edema  is  present,  it  must  be  borne  in  mind  that 
an  edematous  condition  of  the  arm  may  materially  alter  the  results 
of  the  determination,  and  in  such  cases  no  absolute  reliance  can 
be  placed  on  the  data  secured  by  the  sphygmomanometer. 

The  blood-pressure  is  constantly  increased  in  that  type  of  renal 
disease  chiefly  characterized  by,  fibrous  hyperplasia,  and  it  is 
immaterial  whether  this  occurs  in  the  small  granular,  so-called 
"  sclerotic  "  kidney,  or  in  the  large  red  organ;  the  latter,  in  the 
writers'  opinion,  very  often  precedes  the  sclerotic,  and  represents  one 
of  the  early  stages  in  the  development  of  the  small  hard  kidney. 

In  these  conditions  the  blood-pressure  is  almost  invariably 
increased,  often  reaching  above  250  mm.  of  Hg°.  This  can  fre- 
quently be  detected  by  means  of  the  blood-pressure  apparatus, 
long  before  it  is  possible  to  discover  definite  alterations  in  the 
heart  or  liver  by  the  usual  clinical  methods  of  examination.  This 
increase  of  pressure  often  also  renders  a  diagnosis  of  renal  disease 
possible  even  when  oft-repeated  and  careful  urinary  examinations 
fail  to  demonstrate  the  presence  of  any  definite  kidney  lesion. 

In  the  prognosis  of  renal  diseases  blood-pressure  determina- 
tions have  also  given  satisfactory  aid.  In  nearly  all  forms  of 
renal  diseases,  and  particularly  in  those  cases  in  which  fibrous 
hyperplasia  is  the  most  dominant  change,  the  blood-pressure 
varies  but  Httle  when  the  patient  is  progressing  favorably,  and  in 
these  cases  it  has  been  known  to  gradually  drop  almost  to  the 
Jiormal,    invariably    to   rise   again    before   any   acute   manifesta- 


174  THE    BLOOD    IN   DISEASES   OF   THE    KIDNEY 

tions  of  renewed  disease  appear.  A  continuously  high  pressure 
should,  of  course,  warn  the  physician  of  the  danger  of  arterial 
rupture,  and  a  sudden  or  marked  fall  is  a  serious  prognostic  sign 
indicative  of  cardiovascular  failure. 

In  the  treatment  of  renal  disease  the  blood-pressure  has  also 
been  found  a  very  satisfactory  means  of  gaging  the  progress 
made.  Thus,  a  reduction  of  an  abnormally  high  blood-pressure 
may  be  observed  after  the  prolonged  administration  of  potas- 
sium iodid  or  following  the  use  of  chloral  or  other  vasodilators 
and  overstimulation  with  such  drugs  as  caffein,  digitalis,  ergot, 
and  strychnin  is  suggested  by  a  raise  in  pressure.  All  in  all,  a 
regularly  kept  blood-pressure  and  pulse  chart  plotted  with  the 
fluid  and  urine  curves  is,  in  our  experience,  a  most  helpful  guide 
in  the  course  of  a  case  of  nephritis. 

The  writers,  however,  feel  that  there  is  now  a  general  tendency 
to  overestimate  the  dangers  of  high  blood-pressure  and  to  resort 
to  frantic  measures  to  artificially  reduce  it,  quite  forgetting  the 
fact  that  a  high  blood-pressure  is  absolutely  essential  in  some 
types  of  nephritis  for  the  proper  function  of  the  kidney,  and  a 
reduction  of  the  pressure  below  this  point  only  results  in  more 
defective  renal  action  and  in  greater  eventual  strain  on  the  ex- 
cretory and  cardiovascular  system.  We  deprecate  the  routine 
use  of  vasodilators  in  the  high  pressure  of  renal  disease.  Great 
judgment  must  be  exercised  in  this  respect,  and  each  individual 
case  should  be  considered  as  a  law  unto  itself. 


•chapter  VII 
THE  OCULAR  MANIFESTATIONS  OF  RENAL  DISEASES 

By  RICHARD  KALISH,  A.M.,  M.D., 

NEW    YORK 

The  ocular  manifestations  are  of  signal  importance  as  aids  to 
the  diagnosis  of  renal  disease. 

Edema  of  the  lower  eyelids  has,  by  some  writers,  been  consid- 
ered indicative  of  beginning  nephritis,  but  in  the  early  stages  of 
the  disease  this  is  of  only  a  transitory  nature,  and  as  it  likewise 
occurs  in  the  course  of  many  other  systemic  maladies,  it  has  little 
diagnostic  significance.  In  the  terminal  stages  of  nephritis, 
when  the  edema  of  the  eyeUds  has  become  a  permanent  feature, 
the  marked  general  ascites  is  so  distinctive  that  the  presence  or 
absence  of  involvement  of  the  eyeHds  has  no  diagnostic  value. 

Edema  of  the  conjunctiva  has  also  been  attributed  to  nephritis ; 
when  this  condition  accompanies  intra-ocular  inflammation  and 
its  severity  is  disproportioned  to  the  mildness  of  the  deeper  seated 
trouble,  suspicion  should  be  aroused.  In  a  case  seen  by  the 
writer  a  mild  attack  of  rheumatic  iritis  was  compUcated  by  so 
intense  a  chemosis  as  to  prevent  apposition  of  the  eyelids.  Uri- 
nalysis then  disclosed  that  the  patient  was  passing  through  the 
early  stage  of  an  unsuspected  interstitial  nephritis. 

In  patients  who  have  passed  their  fortieth  year  both  subcon- 
junctival and  subcutaneous  hemorrhages,  especially  of  the  lower 
eyelid,  if  recurrent,  demand  an  examination  of  the  kidneys.  The 
hemorrhages  usually  come  on  during  the  night  and  cause  no  pain ; 
the  left  eye  is  the  one  usually  aflfected.  Recurrence  may  ensue 
at  longer  or  shorter  intervals,  often  but  a  few  weeks  intervening 
between  the  attacks.  Occasionally  they  are  the  only  manifes- 
tations of  the  systemic  disease,  and  precede,  by  quite  an  interval, 
the  usual  and  classic  symptoms;  they  may  also  be  associated 
with  other  hemorrhages  incident  to  nephritis,  such  as  purpura, 

175 


176  OCUIyAR    MANIFESTATIONS    OF    RENAI^    DISEASES 

epistaxis,  retinal  hemorrhage,  etc.,  caused  by  a  general  arterio- 
sclerosis, even  if  this  condition  is  not  discernible  in  the  superficial 
arteries. 

Exophthalmos  due  to  effusion  in  Tenon's  capsule  has  been  ob- 
served in  the  course  of  albuminuria.  Recently  Barker  has  called 
attention  to  its  relatively  frequent  occurrence  in  chronic  nephritis. 

External  ophthalmoplegia  has  occasionally  been  observed 
among  the  terminal  symptoms,  but  it  sometimes  occurs  early  in 
nephritis,  and  in  this  event  recovery  is  rapid,  although  relapse 
is  common,  and  muscles  may  be  involved  successively.  These 
paralyses  are  undoubtedly  indicative  of  changes  in  the  cerebral 
vessels  identical  with  those  in  the  retina. 

The  intra-ocular  appearances  accompanying  or  produced  by 
nephritis  are  often  the  first  evidences  of  renal  disease,  and  lead 
to  a  recognition  of  the  malady  before  any  general  symptoms 
arise.  The  most  important  condition  is  albuminuric  retinitis, 
the  ophthalmic  picture  of  which  is  easily  recognized.  The  retina 
usually  appears  as  an  edematous,  light-gray  membrane,  with  or 
without  patches  of  exudation  and  with  darker  stripes  traversing 
its  posterior  part. 

The  arteries  are  reduced  in  size,  thin,  bright  colored,  and  fre- 
quently defined  by  whitish  stripes ;  the  veins  are  broad,  flattened, 
twisted,  and  dark  red  in  color,  and  may  be  covered  by  the  exudate 
or  may  pass  over  it. 

The  outline  of  the  nerve-head  is  hazy,  and  in  some  cases  indis- 
tinguishable, the  optic  disc  apparently  going  over  into  the  retina 
with  no  perceptible  line  of  demarcation.  It  appears  reddish, 
swollen,  and  opaque.  Around  the  nerve-head,  and  several  times 
its  diameter,  is  often  found  a  zone  marked  by  extravasation  of 
blood,  bright  flaming  red  in  color,  with  well-defined  rounded 
spots  or  broad,  flat  stripes,  which  vary  in  size  and  number.  White 
or  yellowish  spots,  often  surrounding  the  optic  nerve,  are  likewise 
seen  in  this  band,  and  small,  shiny,  silvery  points  are  scattered 
over  the  retina.  The  macula  is  usually  red,  and  surrounded  by  a 
band  studded  with  white  spots,  or  with  the  characteristic  halo 
or  star-like  arrangement  of  small  bands  or  spots.  It  is  generally 
accepted  that  there  is  but  one  kind  of  nephritic  retinitis,  and 
that  the  different  forms  and  changes  observed  are  indicative 
only  of  various  stages  of  edema,  hemorrhage,   exudation,   and 


OCULAR   MANIFESTATIONS    OF   RENAL    DISEASES  177 

degeneration.  Albuminuric  retinitis  is  generally  bilateral,  but 
may  not  begin  in  both  eyes  at  the  same  time  nor  develop  equally. 
It  may  occur  at  any  time,  but  comes  on  most  frequently  between 
the  ages  of  fifty  and  sixty,  the  youngest  recorded  case  occurring 
in  a  child  five  years  of  age. 

The  form  of  nephritis  most  frequently  complicated  with  reti- 
nitis is  the  chronic  interstitial  variety,  but  retinitis  may  develop 
in  any  form  of  renal  disease,  even  in  the  acute,  as  in  scarlatina 
or  in  the  course  of  pregnancy.  In  short,  it  may  arise  in  any 
variety  of  renal  disease  that  can  cause  albuminuria,  and  is  found, 
though  rarely,  in  the  course  of  carbuncle,  diphtheria,  erysipelas, 
the  intermittent  fevers,  measles,  smallpox,  typhus,  and  in  poi- 
soning by  alcohol,  cantharides,  croton-oil,  or  lead.  Albuminuric 
retinitis  occurs  in  from  9  to  1 1  per  cent,  of  the  cases  of  nephritis. 

The  extent  of  the  retinitis  bears  no  relation  to  the  intensity 
of  the  renal  affection  or  to  the  amount  of  albumin  contained 
in  the  urine. 

The  degree  of  the  visual  impairment  depends  upon  the  extent 
and  location  of  the  hemorrhages  and  deposits,  rather  than  upon 
the  stage  of  the  malady,  and  varies  from  a  slight  impairment  of 
sight  to  complete  bUndness,  although  this  latter  is  extremely 
rare.  Hemorrhage  into  the  macula  produces  a  marked  diminu- 
tion of  vision,  as  does  optic  neuritis  which  causes  subsequent 
atrophy  of  the  nerve ;  but,  as  a  rule,  visual  reduction  is  markedly 
disproportioned  to  the  ophthalmoscopic  picture. 

The  prognosis  as  regards  life  is  always  grave.  Many  die  during 
the  first  and  few  live  beyond  the  second  year.  These  patients  are 
usually  seen  late  in  the  disease,  after  the  lesions  have  existed  for 
some  time  before  being  discovered  by  the  oculist;  so  it  is  reason- 
able to  infer  that  the  limit  of  two  years  from  the  first  occurrence 
of  the  retinal  complication  is  hardly  accurate. 

Although  various  forms  of  albuminuric  retinitis,  albuminuric 
neuritis,  and  albuminuric  neuroretinitis  have  been  classified  by 
clinicians,  they  cannot  at  times  be  differentiated,  and  may  glide 
insensibly  into  one  another,  and  can  frequently  be  seen  to  merge. 
The  limitations  of  this  article  forbid  their  consideration. 

Uremic  amaurosis  or  amblyopia,  although  less  common,  is 
more  conspicuous  than  the  retinal  complications.     Loss  of  sight 


178  OCULAR    MANIFESTATIONS    OF    RENAL    DISEASES 

in  this  is  sudden,  complete,  and  usually  bilateral,  or  one  eye  may 
be  affected  primarily,  the  other  becoming  blind  in  a  few  hours; 
in  rare  instances  some  light  perception  is  retained.  The  reaction 
of  the  pupil  to  light  is  generally  unimpaired.  The  condition 
of  the  pupil  itself  varies:  sometimes  it  is  dilated,  at  other  times 
it  is  contracted,  and  often  it  remains  unaffected.  The  result  of 
ophthalmoscopic  examination  is  usually  negative,  but  occasion- 
ally a  combination  with  retinitis  exists ;  in  this  event  the  retinitis 
antedates  the  amblyopia.  The  urine  is  scanty  or  may  be  sup- 
pressed, the  specific  gravity  is  high,  albumin  being  present  in 
large  quantities.  Uremic  amaurosis  is  more  common  in  the 
forms  of  nephritis  accompanied  by  uremic  attacks,  as  scarlet 
fever,  pregnancy,  acute  exacerbation  of  the  chronic  form,  etc. 
Restoration  of  sight  is  generally  sudden  and  complete,  varying  in 
time  from  a  few  hours  to  three  or  four  days.  Permanent  blind- 
ness does  not  occur  except  in  cases  in  which  there  has  been  a 
prior  retinitis.     Recurrence  indicates  an  unfavorable  outcome. 

SYLLABUS   OF   OCULAR   CONDITIONS  ACCOMPANYING  OR  PRO- 
DUCED BY  THE  DIFFERENT  TYPES  OF  NEPHRITIS 

1.  Intense  conjunctival  chemosis  occurring  with  or  without 
intra-ocular  inflammatory  diseases. 

2.  Circumorbital  subcutaneous  and  subconjunctival  hemor- 
rhages, if  recurrent  and  in  patients  over  forty  years  of  age. 

3.  Successive  external  ophthalmoplegias. 

4.  Iritis,  choroiditis,  and  iridochoroiditis,  when  not  assignable 
to  other  causes. 

5.  Edematous,  pale-gray  retina,  with  exudate. 

6.  Hemorrhages  and  deposits  in  and  on  the  retina. 

7.  Many  forms  of  retinitis,  neuritis,  and  neuroretinitis  showing 
the  "albuminuric"  picture  on  ophthalmoscopic  examination. 

8.  Contracted,  silver-streaked  arteries  and  dilated,  flattened, 
tortuous  veins. 

9.  Amblyopia  or  amaurosis  with  sudden  complete  blindness, 
temporary  in  character,  without  retinal  damage  or  ophthalmo- 
scopic evidence  of  intra-ocular  disease. 


CHAPTER  VIII 

THE  KIDNEY  IN  ACUTE  INFECTIOUS  DISEASES.-SUP- 
PURATIVE  NEPHRITIS 

THE  KIDNEY  IN  ACUTE  INFECTIOUS  DISEASES 

Relatively  few  diseases  really  arise  primarily  in  the  kidney ;  as 
a  rule,  the  renal  lesion  occurs  secondarily  and  as  a  complication  of 
some  other  pathologic  condition.  For  this  reason  it  is  deemed 
best  to  consider  briefly  the  action  of  the  kidney  in  some  of  the 
more  common  ailments.  Among  these,  the  infectious  diseases 
are  probably  the  most  important,  both  because  of  the  common 
occurrence  and  grave  nature  of  this  class  of  diseases  and  also 
because  of  the  fact  that  serious  renal  complications  are  particu- 
larly prone  to  arise  at  some  tirne  during  their  course. 

Although  the  relative  frequency  of  kidney  lesions  in  the  acute 
infectious  diseases  varies  greatly,  being,  for  example,  very  com- 
mon and  severe  in  scarlatina,  it  is  not  deemed  practicable  to 
consider  the  relationship  of  the  lesion  to  each  individual  disease, 
more  particularly  since  the  variations  that  occur  apparently 
affect  the  degree  or  frequency  more  often  than  they  do  the  patho- 
logic changes. 

There  are  certain  fundamental  reasons  why  renal  disease  so 
commonly  arises  in  the  infectious  processes.  In  these  conditions, 
in  addition  to  the  usual  poisons  elaborated  by  the  metabolism 
of  the  body,  the  renal  tissue  is  required  to  excrete  toxins  generated 
by  bacterial  or  protozoan  growth,  together  with  those  elaborated 
by  a  disordered  metabolism.  The  poisonous  substances  that  the 
kidney  is  called  upon  to  excrete,  therefore,  are  not  those  to  which 
it  has  been  accustomed,  and  thus  renal  irritation  or  incompetency 
is  readily  brought  about. 

In  the  acute  exanthemata,  in  addition  to  getting  rid  of  these 
foreign  toxins,  the  kidney  is  called  upon  to  accomplish,  by  com- 
pensatory excretion,  the  function  normally  carried  on  by  the  skin, 
and  at  the  same  time  the  diseased  skin  presents  a  large  surface 

179 


i8o  ACUTE  infections;  suppurative  nephritis 

for  the  elaboration  of  poisons.  A  practically  analogous  condition 
obtains  in  such  diseases  as  typhoid  and  dysentery,  the  excretory 
powers  of  the  bowel  being  not  only  lessened  or  entirely  lost,  but 
also  affording  a  large  surface  for  the  development  of  abnormal 
metabolic  substances  with  perhaps  actual  toxin  formation.  The 
same  conditions  also  obtain  in  lobar  pneumonia,  in  which,  in 
addition  to  toxin  production  and  diminished  respiratory  excretion, 
a  certain  amount  of  cellular  depression  must  result  from  limited 
oxidation. 

In  even  quite  sharply  localized  infectious  conditions,  and 
especially  in  tonsillitis,  nephritis  develops  with  considerable  fre- 
quency, and  may,  indeed,  be  the  only  evidence  of  a  generalization 
of  the  infection.  In  this  respect  renal  disease  seems  to  approxi- 
mate in  frequency  of  occurrence  endocarditis. 

Before  considering  the  actual  lesions  of  the  kidney  that  com- 
monly originate  in  the  coiu"se  of  the  infections,  it  must  constantly 
be  borne  in  mind  that  albuminuria  and  even  the  presence  of  casts 
and  blood  in  the  urine,  without  actual  nephritis  existing,  are  of 
common  occurrence  in  the  early  stages  of  the  infectious  diseases, 
and  may  appear  entirely  without  infarction  or  other  direct  kidney 
lesions.  Thus  in  nearly  all  the  acute  infections  a  preliminary  stage 
of  engorgement  occurs ;  during  this  period  albumin  and,  in  the  more 
severe  cases,  blood  and  casts  as  well,  may  appear  in  the  urine, 
but  under  favorable  conditions  they  disappear  in  the  course  of 
a  few  hours  or  days,  as  the  circulatory  conditions  become  ad- 
justed. This,  as  stated,  is  manifest  at  the  onset  of  nearly  all  the 
acute  infections.  Under  ordinary  conditions,  as  proper  circula- 
tion becomes  reestablished,  these  elements  disappear  from  the 
urine ;  if,  however,  they  remain  present  over  long  periods,  or  if  a 
secondary  inflammatory  disease  is  set  up  in  the  kidney,  a  true 
nephritis  may  be  ushered  in. 

The  complications  that  arise  as  a  result  of  the  action  of 
infectious  diseases  on  the  kidney  may  be  divided  into  two  groups : 
those  that  originate  in  acute  and  those  that  develop  in  chronic 
or  long-standing  cases.  A  more  minute  classification  is  also 
possible,  and  the  conditions  that  appear  during  the  course  of  the 
acute  infections  may  be  grouped  as  those  that  are  produced 
by  septicemia,  from  the  mere  fact  of  the  presence  of  bacteria 


THE    KIDNEY   IN   ACUTE    INFECTIOUS   DISEASES  l8l 

circulating  in  the  blood,  and  those  that  seem  to  be  caused  chiefly 
by  the  action  of  toxins.  The  most  common  condition  in  which 
the  former  occurs  is  in  septicemia  or  pyemia  from  any  cause 
whatever,  as  in  puerperal  sepsis,  endocarditis,  and  the  like.  How- 
ever, it  must  be  remembered  that  the  mere  presence  of  bacteria 
in  the  blood  is  not  the  sole  or  final  factor,  for  in  all  these  conditions 
toxins,  at  least  in  part,  also  play  a  role;  it  is  rare,  indeed,  that 
bacteria  act  only  in  a  mechanic  or  simple  biologic  capacity. 

The  most  frequent  renal  lesion  occurring  in  septic  conditions  is 
that  of  infarction.  This  is  ordinarily  manifested  by  pain  in  the 
region  of  the  affected  kidney,  and  by  the  sudden  appearance  of 
blood  and  albumin  in  the  urine.  Often,  however,  the  condition 
passes  unnoticed  unless  the  infarct  is  of  considerable  size ;  this  may 
happen  also  when  other  clinical  symptoms  tend  to  obscure  those 
of  infarction.  The  blood  ordinarily  soon  disappears  from 
the  urine,  and  the  condition  is  rarely  diagnosticated  clinically. 
The  infarctions  are,  as  a  rule,  small,  and  involve  chiefly  the  corti- 
cal portions  of  the  kidney,  for  the  reason  that  the  causative 
embolus  commonly  lodges  in  one  of  the  terminal  or  interlobular 
arterioles.  The  area  involved  may,  however,  be  sufficiently  large 
to  result  in  necrosis  of  considerable  portions  of  tissue,  and  the 
particular  danger  in  these  cases  is  that  bacterial  growth  terminat- 
ing in  renal  abscess  may  occur  in  this  necrotic  medium.  If  the 
infarctions  are  of  small  size,  no  symptoms  may  be  present  beyond 
perhaps  the  sporadic  occurrence  of  albumin  and  pus  in  the  urine, 
but  this  depends  largely  on  the  nature  of  the  infecting  organisms ; 
if  they  are  tubercular,  a  general  or  local  tubercular  nephritis  may 
arise;  in  streptococcus  septicemia  a  diffuse  septic  inflammation 
of  the  entire  renal  substance  is  likely  to  occur,  while  in  gonorrheal 
infections,  an  active  suppuration,  usually  more  or  less  localized, 
is  most  likely  to  take  place.  In  pneumonia,  according  to  the 
writers'  observation,  a  diffuse  process  simulating  that  seen  in 
streptococcal  infections  most  frequently  occurs. 

When  the  general  disease  is  characterized  chiefly  by  the  active 
production  of  virulent  toxins,  as  in  scarlatina,  diphtheria,  and 
in  certain  instances  of  lobar  pneumonia,  a  diffuse  hyperemia  of 
the  kidney  takes  place  first,  accompanied  by  albuminuria  and 
casts  that,  even  in  the  most  favorable  cases,  persist  longer  than 


1 82  ACUTE  infections;  suppurative  nephritis 

in  simple  hyperemic  conditions.  If  the  toxemia  is  sufficiently 
active,  this  may  proceed  until  a  diffuse  nephritis  occurs,  and  the 
inflammatory  process  may  become  so  marked  that  a  hemor- 
rhagic infiltration  is  set  up.  Albumin,  blood,  and  epithelial 
casts  appear  in  the  urine,  which  is  also  diminished  in  quantity, 
and  all  the  other  manifestations  of  an  acute  hemorrhagic  nephritis 
become  evident.  This  is  the  picture  most  likely  to  arise  in  scar- 
latina and  in  smallpox.  Even  in  the  milder  cases  a  diffuse  paren- 
chymatous nephritis  is  very  prone  to  develop,  and  this  is  one  of 
the  most  frequent  causes  of  death  occurring  at  the  onset  of  these 
acute  infections,  although  it  may  also  develop  at  any  stage  of  the 
process.  Not  uncommonly  it  is  found  at  autopsy  that  a  single 
kidney  is  so  affected.  When  but  one  kidney  is  the  seat  of  disease, 
the  work  of  excretion  is  thrown  on  the  remaining  organ,  which 
may,  in  consequence,  undergo  compensatory  hyperplasia  or,  on 
the  other  hand,  it  may,  in  turn,  become  diseased,  in  which  case 
a  fatal  termination  generally  ensues. 

As  a  rule,  when  renal  disease  so  occurs  there  is  a  sharp  rise  in  the 
blood-pressure,  with  a  corresponding  retention  of  filterable  nitrogen 
in  the  blood.  In  favorable  instances  pressure  then  falls  to  the 
neighborhood  of  normal,  with  a  drop  in  blood  nitrogen,  to  both 
again  gradually  increase  if  interstitial  changes  occur  in  the  kidney, 
especially  in  or  about  the  glomeruli. 

The  treatment  of  nephritis  arising  in  the  course  of  the  acute 
infections  varies  according  to  conditions  present  in  each  case. 
In  general  it  is  identical  with  that  demanded  in  the  pure  nephritic 
condition.  When  abscess  of  the  kidney  occurs,  it  may  become 
necessary  to  open  and  drain,  but  this  is  rarely  the  case  in  the 
course  of  the  acute  general  disease.  If  a  diffuse  suppuration  is 
present,  which,  as  occasionally  happens,  transforms  the  entire 
substance  of  one  kidney  into  an  abscess  cavity,  nephrectomy  may 
be  imperative.  The  ordinary  methods  of  treating  renal  diseases 
may,  however,  safely  be  employed  in  the  acute  infections;  thus 
the  hot  pack,  diaphoretics,  and  remedies  tending  to  stimulate  excre- 
tion by  the  bowel  are  measures  that  have  been  found  of  decided 
benefit.  The  dietetic  restrictions  ordinarily  prescribed  in  the 
various  forms  of  acute  nephritis  are  indicated  here.  When  ascites, 
hydrothorax,  and  similar  conditions  arise,  the  treatment  should 


THE   KIDNEY  IN  ACUTE   INFECTIOUS  DISEASES  1 83 

first  consist  of  tapping  or  the  employment  of  other  mechanic 
measures  rather  than  of  medicinal  means. 

The  prognosis  is  entirely  dependent  on  the  individual  character- 
istics of  each  particular  case,  and  no  general  statements  in  regard 
to  it  are,  therefore,  possible. 

In  these  renal  complications,  as  in  primary  nephritis,  the  acute 
condition  is  very  prone  to  become  chronic,  and  interstitial  changes 
are  likely  to  take  place;  this  is  seen,  for  example,  in  many  cases 
of  typhoid  fever.  When  the  infection  is  of  long  standing,  it  is 
impossible  to  determine  antemortem,  either  from  a  clinical  or  a 
pathologic  standpoint,  whether  parenchymatous  or  interstitial 
changes  predominate.  As  a  rule,  the  lesions  go  hand  in  hand, 
although  interstitial  hyperplasia  is  more  prominent  in  prolonged 
diseases  or  when  the  blood-vessels  are  extensively  involved. 

When  the  infection  is  in  itself  primarily  of  a  chronic  character, 
as,  for  example,  in  syphilis,  interstitial  manifestations  are  the 
predominating  characteristics  of  the  renal  complications.  Thus 
is  brought  about  the  small  sclerotic  kidney  or,  less  commonly, 
the  large  red  kidney.  In  these  cases,  as  in  the  protracted  sub- 
acute or  acute  infections,  the  degenerative  alterations  are  more  com- 
monly of  the  fatty  type,  differing  in  this  respect  from  the  changes 
seen  in  the  more  active  disease,  in  which  albuminous  degenera- 
tion is  the  dominant  feature.  Fatty  degeneration  may  follow 
the  parenchymatous,  or  it  may  originate  itself  as  a  primary 
change.  Amyloid  degeneration  also  occurs,  especially  in  syphilis, 
tuberculosis,  and  chronic  suppurative  processes,  such  as  osteo- 
myelitis. 

These  renal  complications,  except  when  they  occur  in  tubercu- 
losis, are  clinically  of  much  less  importance  in  the  chronic  infec- 
tious diseases  than  in  the  acute,  for  they  are  not  so  often  the 
immediate  cause  of  death,  unless,  as  is  not  uncommon,  an  acute 
nephritis  becomes  ingrafted  upon  the  chronic.  The  onset  of 
chronic  renal  complications  is  so  insidious  that  it  is  rarely  sus- 
pected early;  prophylaxis  should,  however,  be  provided  by 
giving  particular  attention  to  the  bowel  and  to  the  general 
subsidiary  excretory  functions  of  the  body  in  all  long-standing 
infections. 

The  diagnosis  must  rest  entirely  on  the  usual  manifestations 


184  ACUTE  infections;  suppurative  nephritis 

of  renal  disease — albuminuria,  polyuria,  casts,  edema,  high  blood- 
pressure,  nitrogen  retention  with  diminished  urea  excretion,  and 
the  other  cardinal  symptoms  of  chronic  nephritic  lesions. 

The  treatment  differs  in  no  way  from  that  employed  in  uncom- 
plicating  nephritis  of  the  chronic  t)^pe.  Acute  nephritis  is,  how- 
ever, very  likely  to  arise  as  a  second  complication,  and  may  de- 
mand special  attention. 

Prognosis. — As  a  rule,  renal  involvement  does  not  materially 
alter  the  immediate  prognosis  of  chronic  infectious  disease,  al- 
though it  greatly  diminishes  the  probability  of  ultimate  complete 
recovery.  Unlike  the  acute  form,  it  rarely  acts  as  the  immediate 
cause  of  death  except  when  it  finally  becomes  acute. 

SUPPURATIVE  NEPHRITIS 

Under  this  heading  will  be  considered  the  processes  generally 
classed  under  the  heads  of  exudative  pyelitis,  pyonephrosis,  and 
suppuration  of  the  kidney.  Tuberculosis,  although  coming  prop- 
erly under  this  head,  will,  because  of  its  importance,  be  considered 
separately.  This  plan  has  been  adopted  for  the  reason  that, 
clinically,  the  conditions  are  practically  similar,  the  various 
changes  that  occur  being  often  but  different  stages  of  the  same 
general  process. 

Suppurative  inflammation  of  the  kidney  may  be  brought  about 
by  four  different  methods  of  inoculation:  first,  by  ascending  in- 
fection from  the  lower  urinary  tract;  second,  by  embolic  infarc- 
tion, as  in  general  septicemia;  third,  by  infection  taking  place  in 
the  course  of  what  may  be  regarded  as  the  normal  excretion  of 
bacteria  by  the  urinary  tract;  and  fourth,  by  the  extension  of 
suppurative  processes  into  the  kidney  from  without.  Suppura. 
tion  in  the  kidney  may  be  localized  in  any  portion  of  the  organ,. 
or  it  may  be  diffuse,  the  former  condition  being  the  more  common. 

In  a  large  series  of  postmortems  the  writers  found  ascending 
infection  to  be  by  far  the  most  frequent  cause  of  suppuration.  It 
may  arise  in  any  condition  or  disease  in  which  infection  of  the 
lower  portion  of  the  urinary  tract  has  taken  place,  as,  for  example, 
in  the  exudative  urethritis  of  gonorrhea ;  in  cystitis  or  suppurative 
disease  of  the  ureters,  and,  finally,  in  pyelitis.  As  a  rule,  the 
infection  travels  upward  from  the  urethra,  prostate,  or  bladder, 
infecting  the  various  portions  of  the  excretory  canal  as  it  advances. 


SUPPURATIVE   NEPHRITIS  1 85 

The  mere  presence  of  bacteria,  regardless  of  the  variety  of  organ- 
isms, in  any  of  these  portions  of  the  urinary  tract  is  not  sufficient 
in  itself  to  set  up  the  process.  Another  and  probably  a  more 
important  factor,  that  of  predisposition,  must  also  be  present. 
Thus  pathogenic   bacteria  are   often  found  in   the  urine  under 


Fig.  74. — Double  pyonephrosis  (one-lhird  natural  size). 
Originating  from  a  primary  cvstitis  and  showing  thickening  of  bladder  wall,  dilatation 
of  both  ureters,  and  e.xtensive  necrosis  of  renal  tissue.     Left  kidney  not  opened.     From  a 
specimen  in  the  museum  of  Carnegie  Laboratory. 

phvsiologic  conditions,  and,  as  a  matter  of  fact,  bacteria  are  often 
excreted  by  the  urine  in  both  pathologic  and  physiologic  states 
without  producing  any  local  disease.  This  is  particularly  shown 
in  regard  to  the  colon  bacillus,  which  is  not  uncommonly  found 
in  the  urine,  especiallv  in  constipation  and  in  certain  intestinal 
fermentations.  Two  such  cases  recently  came  under  the  care  of 
the  writers.  In  each  case  purgation  caused  a  temporary  disap- 
pearance of  the  colon  bacillus  from  the  urine,  which  reappeared 


i86 


ACUTE  infections;  suppurative  nephritis 


later.     It  is  quite  possible,  as  asserted  by  Nichols,  of  Montreal, 
that  organisms  so  excreted  may  occasionally  set  up  nephritis. 

W.  H.  Thomson^  has  reported  a  series  of  cases  in  which  colon 
infection  of  the  kidney  set  up  a  diffuse  nephritis  manifested  by 
the  urinary  findings  of  an  active  acute  parenchymatous  nephritis, 
but  v/ith  symptoms  of  much  less  degree.     Colon  bacilli  are  found 


Fig.  7S-— Diffuse  type  of  exudative  or  suppurative  nephritis  occurring  in  a  pneumococcus 
septicemia.  Complete  necrosis  and  replacement  of  tubules  is  shown  in  the  field  :  a,  Malpig- 
hian  body ;  b,  infiltrating  leukocytes. 


in  abundance  in  the  urine  of  these  cases,  which,  notwithstand- 
ing their  very  serious  appearance,  Thomson  finds  recover  quite 
promptly  under  medication  with  urinary  disinfectants,  notably 
urotropin.  We  have  since  had  frequent  occasions  to  verify 
Thompson's  statements  in  regard  to  the  role  which  the  colon  bacil- 
lus may  thus  play,  but  while  the  prognosis  is  far  better  in  those 
^  "  New  York  Medical  Record,"  March  21,  1908. 


SUPPURATIVE   NEPHRITIS  1 87 

cases  than  in  most  others  of  urinary  infection,  a  favorable  result  is 
by  no  means  to  be  definitely  expected,  for  a  general  septicemia  fre- 
quently appears  in  the  condition  or  a  chronic  interstitial  nephritis. 

The  most  frequent  factor  predisposing  in  the  development 
of  suppurative  nephritis  is  hydronephrosis.  This  may  be  induced 
by  any  cause  whatever,  as  when  abnormal  retention  occurs,  as  in 
alcoholic  stupor  or  other  comatose  conditions,  in  obstruction  to 
the  urinary  passages,  as  from  impaction  of  a  calculus,  in  enlarged 
prostate,  urethral  stricture,  and  the  like.  In  all  these  conditions, 
when  the  urine  is  retained  until  abnormal  distention  of  the  bladder, 
ureters,  and  renal  pelvis  takes  place,  the  integrity  of  the  epithehal 
lining  of  these  cavities  becomes  so  much  impaired  that,  if  bacteria 
are  present  in  the  urine,  the  h^^dronephrosis  is  very  prone  to  be 
converted  into  a  pyonephrosis.  Pyonephrosis  may,  however,  be 
excited  by  a  mechanic  irritant;  thus  the  excretion  of  highly 
irritating  urine,  the  presence  of  renal  calcuH,  or  other  similar 
conditions  may  act  as  factors  in  its  production.  From  this  it 
must  not,  however,  be  concluded  that  every  case  of  pyelitis  or 
even  of  pyonephrosis  leads  to  suppurative  nephritis.  Recent 
observ^ations  made  with  the  aid  of  the  cystoscope  have  demon- 
strated that  these  conditions  frequently  exist  and  undergo  spon- 
taneous cure,  or  are  reheved  by  catheterization  and  flushing  of 
the  ureters  and  pelvis. 

When  extension  into  the  body  of  the  kidney  takes  place  from 
these  ascending  infections,  it  occurs  through  the  secretory  tubes 
of  the  medulla.  In  these  cases  the  pyramids  may  be  soon  trans- 
formed into  abscess  cavities  that  retain  the  pyramidal  shape 
and  are  continuous  with  the  distended  pelvis  of  the  kidne}^  This 
process  may  continue  until  the  entire  medulla  of  the  kidnev  is 
involved  or  until  the  cortex  itseh  has  become  gradually  necrosed 
and  the  entire  kidney  transformed  into  an  abscess  cavity  inclosed 
in  the  thickened  capsule,  which,  in  most  cases,  acts  as  a  limiting 
membrane  to  the  suppurative  process.  If  drainage  is  good  and 
if  but  one  organ  is  involved,  as  is  frequently  the  case,  the  process 
may  gradually  be  checked  and  very  slight  constitutional  distur- 
bance may  result.  The  condition  may  often  be  unsuspected  until 
a  urinary  examination  is  made,  which  will  reveal  the  constant 
presence  of  pus  in  abundant  quantities.      It  is  remarkable,  how- 


i88  ACUTE  infections;  suppurative  nephritis 

ever,  to  what  a  limited  degree  urinary  excretion  is  hampered, 
even  when  both  kidneys  are  involved;  in  these  cases  uremia  is 
very  rare,  and  a  double  pyonephrosis  has  been  known  to  exist 
for  years  without  interfering  with  the  business  activity  and  often 
with  but  little  inconvenience  to  the  patient.  Apparently,  such 
a  result  is  dependent  on  the  amount  of  drainage  and,  to  a  certain 
extent,  on  the  bacterial  character  of  the  inflammation. 

Embolic  infarction  of  the  kidney  is  rather  frequent,  owing  to 
the  numerous  terminal  arterioles  that  are  given  off  to  the  cortical 
portions  of  the  kidney,  and  which  are  particularly  prone  to  be  the 
seat  of  emboli.  Embolic  infarctions  occur  most  frequently  in 
pyemia  or  in  septicemia.  In  most  cases  the  infarct  precedes 
suppuration,  the  latter  process  being,  however,  greatly  favored 
by  the  necrotic  material  present  in  the  obstructed  area.  In  a 
considerable  number  of  cases,  particularly  in  malignant  endo- 
carditis and  puerperal  sepsis,  suppuration  seems  to  occur  inde- 
pendently of  the  existence  of  an  infarct. 

Suppurative  nephritis  due  to  the  presence  of  emboli  often  runs  a 
very  mild  course.  Not  infrequently  these  localized  abscesses  of  the 
kidney  become  encapsulated  and  give  rise  to  but  slight  if  any  clini- 
cal manifestation ;  ordinarily,  unless  the  abscess  is  very  large,  or  if, 
as  is  unlikely,  suppuration  spreads,  pyuria  is  absent.  In  short,, 
abscess  formation  in  the  kidney  does  not  display  so  marked  a 
tendency  toward  extension  or  destruction  of  tissue  as  is  the  case 
with  similar  processes  elsewhere.  In  a  few  cases  these  cavities 
may  drain  through  one  of  the  large  tubules;  when  this  occurs,, 
pus  may  be  found  in  small  quantities  in  the  urine.  As  a  rule, 
however,  in  the  writers'  experience,  the  condition  commonly  goes 
unsuspected,  except  in  a  small  number  of  cases  in  which  the  abscess 
is  sufficiently  large  to  present  a  palpable  tumor  or  severe  pain  is 
present. 

Infection  due  to  the  presence  of  pathogenic  organisms  in  the 
urine  is  not  commonly  mentioned  as  a  cause  of  suppuration,  but 
it  is,  nevertheless,  one  of  the  possible  factors  in  its  production. 
In  constipation,  in  general  septic  conditions,  in  infective  icterus, 
and  in  many  other  pathologic  states  bacteria  are  expelled  from- 
the  body  with  the  urine.     Ordinarily,  this  takes  place  without 


SUPPURATIVE   NEPHRITIS  1 89 

serious  consequences  to  the  kidney,  but  instances  undoubtedly 
occur  in  which  bacteria  are  brought  to  the  organ,  and  probably 
because  of  some  mechanic  state  or  a  lowered  resistance  of 
the  renal  tissue,  an  inflammatory  process  is  set  up.  Thus  areas 
of  suppuration  are  occasionally  found  in  the  kidney  when  no 
general  sepsis  has  existed  and  when  ascending  infection  may. 
with  reasonable  certainty,  be  excluded.  Such  cases  usually  fol- 
low the  same  course  as  embolic  infarction,  although  occasionally, 
as  in  Weil's  disease,  diffuse  suppurative  nephritis  may  arise. 

Suppurative  nephritis  originating  from  extension  of  the  process 
into  the  kidney  from  outside  sources  is  somewhat  uncommon, 
except  as  a  sequel  to  traumatism  of  the  kidney;  it  is  quite  rare 
even  in  cases  of  perinephritic  suppuration.  Occurring  under 
these  conditions  it  resembles  perinephritic  abscess,  and  is  per- 
haps best  described  under  that  head. 

Perinephritic  suppuration  may  arise  as  the  result  of  rupture  of 
a  renal  abscess  into  the  perinephritic  tissues,  or  as  an  extension  of 
a  diffuse  suppuration  of  the  kidney  into  this  tissue.  These  are 
among  the  more  infrequent  causes,  although  rupture  of  a  pelvic 
abscess,  particularly  when  pelvic  calculi  are  present,  is  relatively 
frequent.  Most  commonly  it  follows  injuries  received  in  this 
region  or  as  the  result  of  extension  of  suppuration,  as  in  spinal 
caries  or  from  subdiaphragmatic  drainage  of  an  empyema. 
Most  frequently,  perhaps,  it  follows  ulceration  and  perforation  of 
the  intestine,  generally  of  some  portion  of  the  colon  or  appendix. 
It  may  also  arise  in  marasmic  conditions,  particularly  in  chil- 
dren, and  in  cases  of  prolonged  illness,  where  a  generally  depressed 
state  of  the  tissues,  especially  of  the  fatty  variety,  is  present. 

As  a  general  rule,  the  bacteria  found  in  perinephritic  suppura- 
tions are  not  of  the  most  virulent  type.  The  colon  and  the  pro- 
teus  bacillus  are  among  those  most  frequently  observed,  although, 
of  course,  any  member  of  the  intestinal  group  may  be  present. 
As  a  consequence  the  pus  evacuated  from  these  abscesses  gives 
off  a  very  foul  odor,  and  yet  may  remain  in  the  body  for  a  long 
time  without  producing  sepsis  or  marked  general  symptoms. 

Perinephritic  abscesses  may  drain  in  various  directions,  this 
depending  largely  on   the  position  habitually  assumed   by  the 


I90  ACUTE  infections;  suppurative  nephritis 

patient  during  the  course  of  the  disease.  The  pus  may  burrow 
upward  into  the  pleural  cavity,  producing  an  empyema  on  the 
same  or  on  the  opposite  side.  The  abscess  may  rupture  into  the 
peritoneal  cavity,  or  the  pus  may  even  work  its  way  across  the 
retroperitoneal  tissues  to  the  same  region  on  the  opposite  side, 
double  perinephritic  abscess  being  by  no  means  rare.  Probably 
one  of  the  most  common  routes  of  extension  is  along  the  sheath 
of  the  psoas  muscle,  finally  presenting  in  the  groin.  Another 
course,  which  renders  attack  easy,  is  for  the  abscess  to  point  through 
the  muscle  of  the  back  or  side. 

Diagnosis. — Unless  pus  can  be  demonstrated  in  the  urine  col- 
lected before  bladder  contamination  has  been  possible,  the  diagno- 
sis of  suppurative  nephritis  is,  as  has  been  stated  previously, 
very  difficult  and  often  impossible.  When  pus  is  present,  it  may 
be  found  in  but  small  amount,  particularly  in  the  diffuse  forms; 
when  it  escapes  from  a  localized  abscess,  it  may  be  present  at  one 
time  and  absent  at  another.  Blood  is  rarely  seen  except  in  the 
early  stages  of  traumatic  cases,  and  casts  may  or  may  not  be 
present;  pus-casts  are  occasionally  found,  however,  even  when 
free  pus-cells  seem  to  exist  only  in  very  small  numbers.  The 
urine  may  be  either  acid  or  alkaline  in  reaction,  this  depending 
largely  on  the  nature  of  the  organisms  present ;  usually,  when  the 
infection  is  an  ascending  one,  it  is  alkaline.  As  a  rule,  there  is 
no  change  in  the  amount  of  urine  secreted,  and  at  times  it  may 
contain  particles  of  necrotic  renal  tissue,  the  nature  of  which  may 
be  recognized  under  the  microscope. 

When  the  infection  has  been  ascending,  the  diagnosis  is,  as  a 
rule,  greatly  facilitated  by  the  history  of  the  case,  by  the  presence 
of  urethritis  or  cystitis,  or  by  the  discovery  of  an  obstruction 
to  the  ureter  or  to  the  outflow  from  the  bladder.  It  will  occa- 
sionally be  found,  strangely  enough,  that  no  cystitis  or  inflamma- 
tory disease  of  the  lower  urinary  passages  exists  (having  under- 
gone cure),  whereas  the  pyonephrosis  or  pyeHtis  that  occurred  sec- 
ondarily is  still  present.  From  this  it  will  be  seen  that  a  normal 
condition  of  the  lower  urinary  passages  does  not  exclude  the 
possibility  of  these  channels  having  been  the  original  seat  of 
infection. 


SUPPURATIVE   NEPHRITIS 


191 


Although  the  condition  of  the  urine  is  by  far  our  most  important 
aid  in  the  diagnosis  of  this  disease,  other  factors  are  to  be  consid- 
ered. For  example,  fever  may  be  present,  either  with  or  without 
the  occurrence  of  pyuria;  on  the  other  hand,  this  appears  to  be 
largely  dependent  on  the  bacterial  nature  of  the  process;  thus 
extensive  renal  suppuration,  usually  of  a  more  or  less  chronic 
type,  has  frequently  been  found  without  any  hyperpyrexia  occur- 
ring. A  more  constant  finding  is  a  polynuclear  leukocytosis, 
although  this  may  also  be  absent,  and,  more  particularly,  in  the 
very  cases  in  which  pyrexia  is  likewise  absent. 

There  are  no  symptoms  that  are  characteristic  of  renal  suppura- 
tion other  than  those  common  to  a  suppurative  processs  occurring 


Fig.  76.^Method  of  expressing  pus  from  kidney  pelvis  into  the  bladder. 


elsewhere  in  the  body.  Except  when  the  urinary  findings  indicate 
the  probable  seat  of  the  process,  or  the  somewhat  unusual  symp- 
toms of  renal  tumor  or  fluctuation  in  the  kidney  region  are  present, 
a  diagnosis  is  not  generally  possible.  Occasionally,  however, 
the  patient  will  complain  of  severe  pain  in  the  renal  region,  and 
while  this  is  not  of  much  value  in  the  diagnosis,  it  is  a  point  to  be 
considered. 

The  tendency  for  a  patient  to  draw  up  the  leg  on  the  affected 
side  is  somewhat  indicative  of  pus  either  in  or  around  the  kidney. 
Catheterization  of  the  ureters  furnishes  one  of  the  surest,  if  not 
the  safest,  means  of  diagnosing  pus  within  the  kidney.  Some^ 
experience  is  necessary,  however,  in  performing  this  operation, 
and  in  interpreting  the  findings  from  it  correctly,  for  the  passage 
of  the  catheter  itself  will  often  cause  enough  irritation  to  render 


192 


ACUTE  infections;  suppurative  nephritis 


the  urine  slightly  cloudy.  Microscopically,  a  few  pus-cells  may 
be  found,  but  this  alone  does  not  necessarily  indicate  that  a 
suppurative  nephritis  is  present.  In  small  kidney  abscesses,  in 
which  there  is  good  drainage,  it  should  be  remembered,  sponta- 
neous cure  often  results;   when,  therefore,  a  small  quantity  of 


Fig.  77. — Method  of  expressing  pus  from  the  kidney  pelvis  into  the  bladder,  continuation  of 

figure  66. 

true  pus  is  found  in  the  urine  obtained  by  ureter  catheteriza- 
tion, this  is  not  necessarily  an  indication  for  the  performance  of 


Fig.  78. — Vibratory  method  of  expressing  or  massaging  pus  from  the  renal  pelvis  into  the 

bladder. 


nephrectomy,  or  even  of  lavage  of  the  pelvis  of  the  kidney  by 
means  of  the  ureter  catheter. 

A  valuable  method,  and  one  coming  into  more  general  use,  for 
diagnosing  the  presence  of  pus  in  the  kidney  is  that  of  making  an 
examination  of  the  urine  before  and  after  performing  massage 
of  the  kidney  region  and  along  the  course  of  the  ureter.  The 
writers'  attention  was  very  recently  directed  to  the  value  of  this 
diagnostic  measure  by  the  House  Staff  at  the  City  Hospital  of 
New  York.  In  one  case  the  massage  forced  so  large  an  amount 
of  pus  from  the  kidney  into  the  bladder  that  the  gross  appearance 
of  the  urine  was  materially  altered.  This,  together  with  the  occur- 
rence of  the  general  symptoms  of  sepsis,  was  considered  evidence 


SUPPURATIVE   NEPHRITIS  1 93 

abscess  of  the  kidney.  If  this  method  demonstrates  the  presence 
of  a  considerable  amount  of  pus,  nephrectomy  is,  as  a  rule,  indicated. 
This  method  as  a  means  of  diagnosis  has  been  advocated  by  Gior- 
dano, of  Venice.^  This  observer  places  the  patient  at  rest,  emp- 
ties the  bladder,  performs  massages  over  the  kidney  and  along  the 
course  of  the  ureter,  and  then  collects  the  urine.  After  this  he 
washes  out  the  bladder,  performs  massage  of  the  other  side,  and 
collects  the  urine  again.  When  the  urine  of  one  side  is  bloody, 
he  considers  this  an  indication  of  the  presence  of  renal  calculus. 
G.  Nicholich,  another  Italian  observer,  advocates  the  leaving  of  a 
catheter  in  the  previously  washed-out  bladder  and  massaging 
first  one  side,  and  then  the  other. 

As  has  previously  been  mentioned,  the  writers  consider  this 
massage  or  the  making  of  pressure  over  the  kidney  and  along  the 
course  of  the  ureter  as  one  of  the  most  valuable  diagnostic  aids 
at  our  command,  and  recommend  its  use  not  only  for  the  purpose 
of  demonstrating  the  presence  or  absence  of  pus  in  the  kidney, 
but  as  furnishing  evidence  of  the  presence  of  renal  calculi,  besides 
giving  general  information  as  to  the  conditions  of  these  organs. 

Treatment. — Ordinarily  the  treatment  of  an  abscess  in  or 
around  the  kidney  is  essentially  surgical  and  consists  in  drain- 
age or  the  perf9rmance  of  either  nephrotomy  or  nephrectomy; 
operations  which  will  be  described  in  detail  further  on  (p.  288). 
Cases,  however,  occur  in  which  surgical  intervention  either  is 
inadvisable  or  is  not  permitted ;  these  must  be  put  on  a  strict 
hygienic  and  dietetic  regime  and  symptomatic  and  medical 
measures  may  be  used  to  relieve  distress  or  to  minimize  the  effects 
of  disease.  Urotropin  used  carefully  but  in  full  doses  apparently 
has  given  very  satisfactory  results  in  certain  of  these  cases,  and  the 
use  of  vaccines,  either  autogenous  or  stock,  is  thoroughly  justified 
after  bacterial  examination  has  demonstrated  the  nature  of  the 
organisms  present. 

^  "  La  Semaine  Med.,"  March,  30,  1094. 
13 


CHAPTER  IX 
BRIGHT'S  DISEASE 

THE  PATHOLOGY  OF  BRIGHT'S  DISEASE 

There  is  no  more  difficult  problem  in  medicine  than  to  make 
a  comprehensive  and  accurate  determination,  from  the  clinical 
aspects,  of  the  existence  of  Bright's  disease,  and  to  tell,  from  these, 
the  precise  lesions  that  occur  in  the  kidney,  or  vice  versd.  While 
the  recent  researches  in  regard  to  kidney  disturbances  have  thrown 
very  much  light  on  these  diseases,  it  still  remains  most  difficult 
to  determine  antemortem  from  all  the  findings  in  any  case  what  the 
postmortem  renal  lesions  will  be  found  to  be.  Not  uncommonly 
cases  that  appeared  clinically  to  be  examples  of  typical  acute 
nephritis  are  shown  at  autopsy  to  have  been  but  an  acute  exacer- , 
bation  of  a  chronic  or  subacute  one.  On  the  other  hand,  cases 
running  a  slow  and  relatively  mild  course,  typical  of  the  chronic 
form  of  the  disease,  may  be  found  to  be  due  to  purely  acute  and 
active  lesions.  While  Cabot,  in  his  conclusions,  may  take  too 
extreme  a  view  when  he  declares  that  we  can  tell  nothing  of  the 
character  of  the  lesion  from  the  clinical  aspects  presented  and 
from  an  examination  of  the  urine,  yet  those  who  have  followed 
cases  from  onset  to  autopsy  cannot  but  agree  with  him  in  the  main. 
It  must  be  acknowledged  that  to  Cabot,  perhaps  more  than  to  any 
other  observer,  is  due  the  credit  for  an  honest  realization  of  the 
difficulties  of  making  an  exact  diagnosis  in  inflammatory  and 
degenerative  lesions  of  the  kidney. 

When  accurate  methods  for  examining  the  urine  were  first 
introduced  it  seemed  as  if  through  them  some  positive  infor- 
mation might  be  gained  of  renal  disease.  In  the  main  this  is 
true,  although  it  must  be  said  that  no  broad-minded  clinician 
now  feels  that  he  can  rely  absolutely  on  even  this  aid  in  more 
than  the  "average"  case.  Recognizing  fully  the  tremendous  ad- 
vantage which  the  chemical  examinations  of  the  blood  have  given 
us,  together  with  the  enlightening  data  of  sphygmomanometry  and 

194 


PATHOI.OGY   OF   B RIGHT'S   DISEASE)  1 95 

of  the  tests  for  renal  permeability,  we  cannot  feel  that  even  the 
great  strides  of  recent  study  and  experience  have  materially 
changed  this  statement.  Certainly  Cabot's  statistics  and  those 
of  later  observers  in  regard  to  this  matter  must  lead  to  the  adop- 
tion of  even  a  more  pessimistic  view  of  absolute  anatomic  diagnosis 
in  this  disease. 

For  this  reason  the  writers  have  long  ago  abandoned  the 
attempt  to  make  an  exact  diagnosis  in  regard  to  the  anatomic 
condition  of  the  kidney  from  the  clinical  findings  or  symptoms, 
and  rely  chiefly  on  the  determination  of  the  physiologic  possi- 
bilities, which,  after  all,  are  the  more  important,  since  on  these, 
and  not  on  the  exact  anatomic  changes,  rests  the  hope  of  effecting 
reparation  and  recovery  of  function.  Nevertheless,  the  study 
of  the  pathologic  anatomy  of  the  kidney  in  Bright' s  disease  is 
most  important,  particularly  in  considering  the  treatment  of 
mild  or  early  cases,  and  in  attempts  at  prophylaxis.  It  is  neces- 
sary, besides,  to  establish  a  basis  of  definite  anatomic  lesions  on 
which  to  erect  our  superstructure  of  symptomatology,  and  on 
which  to  formulate  our  course  of  treatment.  We  shall  not  feel 
that  the  newer  methods  of  study  and  diagnosis,  as  from  chemical 
investigation  of  the  blood,  are  wholly  satisfactory  and  conclusive, 
until  these  make  it  possible  to  definitely  prognose  the  anatomic 
pictures  found  at  autopsy.     We  are  still  far  from  such  success. 

All  kidney  lesions  in  Bright' s  disease  are  separable  theoret- 
ically, practically,  and  anatomically  into  two  large  classes — (i) 
Those  in  which  true  inflammatory  lesions  are  present  in  the  kid- 
ney tissue;  (2)  those  characterized  by  degenerative  changes  in 
the  parenchyma.  In  adopting  this  simple  classification  it  must 
be  borne  in  mind,  of  course,  that,  though  it  may  exist  theoretic- 
ally, one  never  sees  a  pure  type  of  either  class,  and  the  division 
holds  only  in  that  in  most  cases  either  degenerative  or  inflammatory 
lesions  predominate. 

A  further  subdivision  into  acute  and  chronic  is  usually  possible 
both  clinically  and  anatomically,  and  in  this  discussion  an  attempt 
will  be  made  to  adhere  as  closely  as  possible  to  this  simple  classifi- 
cation, believing  it  to  be  that  most  useful  to  the  study  and  man- 
agement of  cases  of  Bright' s  disease,  and  most  helpful  to  a  proper 
understanding  of  the  disease. 


196 


bright's  disease 


Acute  Bright's  disease  may  be  due  to  any  agent  or  factor  that 
is  productive  either  of  acute  inflammatory  foci  or  of  active  paren- 
chymatous degeneration  in  the  substance  of  the  kidney.  It  is 
hardly  necessary  to  state  that  when  the  inflammatory  process 
amounts  to  actual  suppuration,  it  should  not  be  considered  as 
Bright's  disease,  but  as  a  suppurative  nephritis. 

Among  the  agents  most  commonly  productive  of  such  inflam- 
matory lesions  in  the  substance  of  the  kidney  must  be  mentioned 
those  vascular  disturbances  that  give  rise  to  sudden  hyperemic 
conditions  of  the  organs;  this  may  be,  in  a  certain  number  of 
cases,  of  neural  origin,  or  it  may  be  due  to  those  vague,  but  none 
the  less  important,  derangements  of  the  vascular  supply  that 
follow  exposure  to  excessive  cold,  heat,  or  physical  or  mental 
strain.     Although  the  complete  theoretic  understanding  of  these 


h  H^a 


Fig.  79. — Acute  hemorrhagic  nephritis,  occurring  in  a  case  of  scarlet  fever.  The  urine 
contained  large  quantities  of  blood:  a.  Malpighian  bodj- ;  ^.extensive  interstitial  hemor- 
rhage causing  isolation  of  tubules;  c,  hemorrhage  into  lumen  of  convoluted  tubule. 

factors   may   be    unsatisfactory,    clinical   experience   has    shown 
beyond  doubt  that  they  cause  acute  nephritis. 

Sudden  checking  of  the  function  of  other  excretory  organs,  as 
the  skin  or  bowel,  with  the  resulting  hyperemia,  may  be  followed 


PATHOLOGY    OF    BRIGHT'S   DISEASE  197 

— and,  in  fact,  often  is  followed — by  the  development  of 
inflammatory  changes  in  the  renal  tissue,  in  this  way  setting  tip  a 
true  acute  nephritis.  Irritants  circulating  in  the  blood,  such  as 
the  metallic  poisons,  alcohol,  spices,  and  condiments,  may  also 
act  in  a  similar  manner.  More  frequently  we  find  that  poisons 
generated  in  the  course  of  the  various  infectious  processes,  and 
brought  to  the  kidney  for  excretion,  act  as  inflammatory  exci- 
tants, although  in  most  cases  these  agents  affect  chiefly  the  renal 
epithehum,  causing  degenerative  disease  and  resulting  in  that 
type  of  nephritis  which  we  are  attempting  to  separate  from  the 
true  inflammatory  form.  More  often  than  is  generally  conceded, 
metabolic  substances  that  result  from  the  abnormal  breaking  up 
of  normal  food  products  or  tissue,  or  those  that  follow  from  the 
natural  disintegration  of  abnormal  metabolic  substances, — ma- 
terials exciting  inflammatory  reactions, — are  brought  to  the  kid- 
ney. There  can  be  Httle  doubt  but  that  many  of  the  apparently 
idiopathic  cases  of  nephritis  are  really  brought  about  in  this 
manner,  and  it  becomes  the  duty  of  the  physician  to  study  the 
metabolic  functions  of  his  patient  as  fully  as  possible.  By  mak- 
ing frequent  examinations  of  the  urine  and  the  feces  and  with 
close  attention  to  the  digestive  functions,  metaboUc  disturbance 
may  usually  be  detected  early  and  corrected,  thus  preventing 
the  onset  of  renal  compHcations. 

The  actual  changes  in  the  kidney  substance  in  this  inflamma- 
tory type  of  Bright's  disease  vary  greatly  according  to  virulence 
and  the  rapidity  of  action  of  the  etiologic  agent,  and  doubtless 
according  to  the  natural  resistance  offered  by  the  renal  tissue 
and  also  to  a  certain  degree  on  the  anatomic  portion  of  the  kidney 
chiefly  affected,  as  the  glomeruli  or  the  tubules,  etc. 

In  general  it  may  be  stated  that  renal  lesions  may  manifest 
all  the  types  of  inflammation  seen  elsewhere  in  the  body.  In  a 
certain  number  of  cases,  particularly  in  those  of  sudden  onset, 
intense  hyperemia  develops,  often  with  diapedesis  of  the  w^hite 
and  red  blood-corpuscles,  which  may  then  appear  in  the  urine. 
Naturally,  cell-infiltration  is  found  to  be  most  marked  about  the 
blood-vessels,  and  particularly  in  the  cortex  of  the  organs,  where 
the  capillary  distribution  is  most  abundant.  Proliferation  of 
the  connective-tissue  cells  in  the  adventitia  of  the  larger  vessels 


198  bright's  disease 

and  the  interstitium  of  the  kidney  tissue  follows,  and  areas  of 
small  round-cell  infiltration  appear  about  the  vessels  and  lym- 
phatics. Serum  may  be  thrown  out  in  abundance,  and  at  post- 
mortem examination  the  cut  sections  of  many  such  kidneys  drip 
serum  in  great  quantities.  Associated  with  these  changes  more 
or  less  degeneration  and  desquamation  of  renal  epithelium  take 
place,  and  these  fragmented  cells,  together  with  serum  and  blood, 
collect  in  the  tubules  and  are  washed  out  as  casts  of  various 
types. 

The  vessels  remain  hyperemic  throughout,  and  even  gross  in- 
spection of  the  organ  is  sufficient  to  demonstrate  the  engorged 
capillaries. 

In  this  type  of  nephritis  healing  presupposes,  of  course,  the 
removal  of  the  etiologic  causes,  the  reestablishment  of  nor- 
mal circulation,  absorption,  by  the  blood  and  lymph,  of  the  liquid 
portions  of  the  inflammatory  exudate,  and  the  disintegration  of 
the  extravasated  blood-cells,  broken-down  epithelium,  and  con- 
nective tissue,  which  may  either  be  carried  off  in  the  urine  or  be 
picked  up  by  phagocytic  leukocytes  and  endothelial  cells  and 
then  may  be  taken  away  by  the  lymph-stream.  With  the  re- 
moval of  the  exciting  factors  and  of  the  inflammatory  exudate 
restitution  of  the  desquamated  epithelium  by  a  multiplication 
of  the  remaining  cells  readily  takes  place,  and  the  lesions  of  the 
urinary  tubes  are  quickly  repaired.  Quite  another  and  more 
serious  matter  is  the  disposition  of  the  newly  formed  connective- 
tissue  cells,  for,  with  the  growth  of  this  tissue,  new  blood-vessels 
have  developed  and  a  definite  structure  has  been  built  up  that  is 
best  described,  perhaps,  as  a  type  of  granulation  tissue.  Assum- 
ing that  the  acute  inflammation  has  entirely  subsided,  either  this 
newly  formed  tissue  must  break  down  and  become  absorbed, — 
a  result  that  the  writers  believe  but  rarely  takes  place, — or  it 
must  pass  on  to  the  formation  of  adult,  that  is,  scar,  tissue, 
with  its  well-known  tendency  to  contraction.  In  this  manner 
the  chronic  sclerotic  type  of  nephritis  may  readily  follow  the 
acute  disease. 

It  has  appeared  impracticable  to  attempt  the  still  further  di- 
vision of  this  form  of  nephritis  into  subclasses,  since  the  type  in 


PATHOLOGY   OF   BRIGHT'S    DISEi^.SE 


199 


each  case  depends  not  on  essential  alterations  in  the  cause  or 
nature  of  the  disease,  but  rather  on  the  form  or  degree  to  which 
the  inflammatory  process  progresses. 

It  is  notably,  if  not  exclusively,  in  this  type  of  case,  especially 
where  the  glomeruli  are  mostly  involved,  that  increase  in  arterial 
tension  develops,  and  concomitant  with  it  the  retention  of  nitrog- 
enous bodies  in  the  blood;  usually  sooner  or  later  sodium  chlorid 
and  urea  also  fail  to  be  normally  excreted,  and  either  gather  in  the 
tissues  or  in  the  body  fluids,  causing  or  favoring  edema  and  other 
marked  circulatory  changes.  Chase,  Halsey,  and  others  of  their 
school  insist  that  the  retention  of 
uric  acid  in  the  blood  is  among  the 
very  earliest  tendencies  in  these 
cases.  It  is  certainly  true  that  the 
blood  uric  acid  content  is  high  in 
most  of  these  instances,  but  we  are 
not  prepared  to  fully  adopt  their 
viewpoint  in  this  regard.  Fully  de- 
veloped cases  of  this  type  are  unable 
to  concentrate  their  urine. 

The  second  type  of  acute  nephri- 
tis, or  Bright's  disease,  according 
to  our  classification,  comprises  those 
cases  that  are  chiefly  typified  not 
by  inflammatory,  but  by  degenera- 
tive alterations;  although,  as  has 
previously  been  stated,  these  two 
processes  are  usually  associated  to 
a  greater  or  less  degree,  and  classi- 
fication is  only  possible  from  the 
predominating  lesion.  The  degen- 
erative type  of  nephritis  occurs  most  commonly  as  a  result  of 
toxemia,  particularly  that  resulting  from  such  processes  as  diph- 
theria, sepsis,  and  as  in  certain  cases  of  typhoid  fever.  It  occurs 
also,  and  even  more  commonly  than  the  inflammatory  type,  in 
cases  of  metabolic  disturbances.  The  process  is  often  ushered  in 
without  exhibiting  the  slightest  inflammatory  manifestations  symp- 


Fig.  80. —  Chronic  interstitial  ne- 
phritis. (One-half  natural  size.)  Both 
organs  from  same  subject.  Case  of 
chronic  lead-poisoning.  Specimens  in 
museum  of  Carnegie  Laboratory. 


200 


bright's  disease 


tomatically  or  in  the  renal  tissue,  and  solely  by  the  degenerative 
changes  in  the  epithelium ;  almost  always,  however,  inflammatory 
changes  eventually  follow  to  some  extent. 

As  is  naturally  to  be  expected,  the  disease  affects  particularly 
the  cells  of  the  convoluted   tubules,  and  is  first   manifested  by 


Fig.  8i. — Chronic  interstitial  nephritis,  showing  adherence  of  capsule   and  roughened 
surface.     Natural  size. 

evidences,  in  these  cells,  of  an  acute  parenchymatous  or  albumi- 
nous, later  associated  with  a  fatty,  degeneration.  The  cyto- 
plasm of  the  cells,  and,  in  more  severe  instances,  the  nucleus  as 
well,  becomes  turbid  and  swollen  from  the  transformation  of  the 
normal  cell-substances  into  lower  albuminous  granules.  When 
the  process  becomes  sufficiently  marked,  the  cell  begins  to  disinte- 
grate, and  fragments  are  thrown  off  into  the  urine;  or,  in  a  more 
active  process,  the  entire  cell  may  thus  be  desquamated,  and  if 
fragments  appear  in  abundance  in  the  urine,  unaccompanied  by 
blood-cells  or  other  inflammatory  products,  this  is  more  or  less 
diagnostic  of  this  form  of  renal  disease.  Casts  form,  as  in  the  first 
variety,  for  associated  with  the  degenerative  changes  in  the  renal 
cells  is  a  similar  process  affecting  the  endothelium  of  the  capilla- 
ries and  lymphatics. 


PLATE   VII 


Large  white  kidney.      (Two-thirds  natural  size.)      (From  a  specimen  in  the 
Museum  of  Carnegie  Laboratory.) 


PATHOLOGY    OF   BRIGHT's   DISEASE 


20I 


Changes  in  the  connective  tissues  arise  in  this  form  only  as 
compUcations,  and  the  heahng  process  is  so  much  simpler  that 
the  cases  are  quite  distinctly  differentiated  from  the  former  class 
by  their  relatively  rapid  and  permanent  recovery,  under  proper 
conditions.     The  heahng  process  consists  simply  in  the  complete 


i^  . 


«  i* 


Fig.  82. — Combined  parenchymatous  and  fatty  degeneration  of  kidney,  from  a  case  of 
puerperal  eclampsia  :  a,  Convoluted  tubules  showing  extensive  degeneration;  d,  collecting 
tubules  ;  c,  cells  showing  profound  parenchymatous  degeneration  ;  rf,  oil  globules  in  cytoplasm 
of  degenerated  cells. 

desquamation  of  those  cells  that  are  too  much  diseased  to  permit 
restitution  to  take  place,  and  the  replacement  of  these  discarded 
cells  by  others  that  arise  by  cell  division  from  the  remaining  and 
relatively  normal  cells.  This  process  is  readily  brought  about  in 
most  cases,  and  may  result  in  such  complete  repair  that  the  organs 
become  relatively  normal  again.  This  rarely  or  never  occurs  in 
cases  associated  with  true  inflammatory  alterations,  especially 
where  the  glomeruli  have  been  seriously  compromised. 

When  more  or  less  complete  destruction  of  the  parenchyma  has 
taken  place,  new  tubules,  supporting  tissue,  and  even  glomeruli 
may  all  be  re-formed  in  young  tissues ;  the  same  manner  of  repair 


202 


BRIGHT' S  DISEASE 


may  also  take  place,  though  in  lesser  degree,  in  the  inflammatory 
forms.  It  must,  however,  be  repeated  that  pure  instances  of  the 
degenerative  types  of  nephritis  are  rare. 

As  a  rule,  the  chronic  inflammatory  variety  of  nephritis  is  a 
sequel  to  the  acute  disease  of  the  same  type,  although  it  may 
follow  the  degenerative  form,  particularly  when  it  is  long  con- 
tinued and  associated  with  extensive  destruction  of  tissue.  In 
this  chronic  type  of  inflammatory  nephritis  several  classifications 


Fig.  83. — Profound  degree  of  parenchymatous  degeneration  of  the  kidney  occurring  in  a 
case  of  toxic  lobar  pneumonia  :  a,  a,  Congested  capillaries  ;  d,  d,  convoluted  tubules  showing 
advanced  parenchymatous  degeneration  with  necrosis  and  desquamation  of  the  epithelium ; 
injected  glomerulus. 

are  commonly  made,  the  organ  being  denominated  as  the  large 
red  kidney,  the  small  sclerotic  kidney,  and  so  on.  It  is  the  writers' 
belief  that  it  is  absolutely  impossible  to  differentiate  these  types 
clinically,  nor  does  the  new  blood  chemical  changes  assist  in 
this,  and  since  they  really  represent  but  modifications  of 
the  same  pathologic  process,  a  minute  classification  accord- 
ing to  mere  gradations  of  the  identical  disease  process  seems 
unnecessary.  When  the  disease  is  characterized  by  active  hyper- 
plasia of  the  interstitial  tissue,  often  associated,  it  is  true,  with 
parenchymatous  degeneration  and  hyperplasia  as  well,  the  size 
of  the  organ  increases,  this  increase  being  chiefly  due  to  the  pro- 


PATHOLOGY    OF   BRIGHT' S    DISEASE 


203 


duction  of  granulation  tissue  in  the  organ;  if,  on  the  other  hand, 
this  hyperplastic  process  is  less  active,  the  newly  formed  tissue  is 
allowed  to  develop  until  it  assumes  a  more  adult  type,  becoming, 
namely,  cicatricial  tissue,  and  the  small  or  sclerotic  form  of  kid- 
ney results.  In  either  case  the  functionating  epithelium  and  the 
vessels  are  compressed,  and  both  venous  and  lymphatic  return 
flow  is  impeded.     This  greatly  diminishes  the  functional  possi- 


•4    ^  • 


'4  ^f' 


%^^ 


Fig.  84. — Kidney  of  rat  showing  profound  fatty  degeneration  following  experimental 
arsenical  poisoning;  section  stained  with  osmic  acid  ;  a,  Convoluted  tubules  with  fat  globules 
stained  black  ;  d,  Malpighian  body. 


bilities  of  the  organs,  and  the  excretory  process,  in  so  far  as  the 
kidneys  are  concerned,  becomes  more  nearly  a  simple  filtration 
or  osmosis,  as  is  shown  by  the  chemic  nature  of  the  urine.  An 
increase  in  blood-pressure  at  first  with  adequate  and,  finally,  with 
a  failing  pidse-pressure  appears,  nitrogen  retention  becomes 
marked,  and  it  is  impossible  to  bring  about  urine  concentration  by 
either  dietetic,  fluid  intake,  or  medicinal  means.  The  overgrowth 
of  connective  tissue  chiefly  works  harm  by  effecting  direct  compres- 


204 


BRIGHT  S   DISEASE 


sion  and  consequent  atrophy  of  the  secreting  tubes,  and  notably, 
according  to  Volhart  and  Fow,  of  the  glomeruli.  Occasionally 
the  newly  formed  tissue  chiefly  compresses  the  collecting  tubules, 
and,  as  continued  secretion  takes  place,  the  tube  above  the  point 
of  stricture  becomes  dilated  and  the  formation  of  cysts,  often  of 
considerable  size,  and  closely  simulating  those  of  congenital 
cystic  kidney,  occurs. 

It  is  obvious  that  the  constantly  progressive  hyperplasia  of  the 
connective  tissue,  with  or  without  resulting  contraction,  causes 
serious  inhibition  of  the  renal  function,  even  though  the  interstitial 
hyperplasia  is  occasionally  associated  with  parenchymatous  pro- 
liferation in  limited  degree.  It  is,  therefore,  found  that  in  this 
disease  compensatory  excretion  is  carried  on  by  the  other  excre- 


V^'        tfw'^*?'  *  "• 


a 


*  # 

***^ 


'<     -tf.,^'' 


Fig.  8$. — Chronic  interstitial  nephritis,  from  a  case  of  chronic  alcohoHsm:  a,  Glomerulus 
replaced  by  hyperplastic  connective  tissue ;  6,  diffuse  hyperplasia  of  stroma  ;  c,  compressed  and 
atrophied  tubules  filled  by  degenerated  epithelial  cells. 


tory  organs,  particularly  by  the  skin  and  bowel,  so  it  frequently 
happens  that  when  either  of  these  also  become  diseased,  the  addi- 
tional work  thrown  on  the  crippled  kidneys  may  set  up  an  acute 


PATHOLOGY    OF    BRIGHT'S    DISEASE  205 

hyperemia  and  an  exacerbation  of  the  inflammatory  process,  a 
common  termination  to  this  form  of  renal  disease. 

It  is  unusual  to  find  the  chronic  degenerative  type  of  Bright's 
disease  entirely  uncomplicated  by  inflammatory  lesions,  and 
the  presence  or  absence  of  these  changes  determine,  to  a  large 
degree,  the  activity  of  the  morbid  process.  When  the  generation 
of  new  parenchyma  cells  keeps  pace  with  their  destruction,  and  the 
organs  are  still  able  to  handle  satisfactorily  the  solids  of  the  urine, 
notably  the  uric  acid,  urea,  and  sodium  chlorid,  the  process  may 
be  continued  indefinitely  until  some  other  factor  arises  that  inter- 
feres with  this  compensation,  resulting  commonly  in  acute  out- 
breaks of  nephritis  or  in  uremia.  One  can  readily  understand  how, 
in  nearly  pure  cases  of  this  kind,  the  disease  may  run  a  prolonged 
course,  albumin  being  constantly  found  in  the  urine,  and  yet  the 
kidney  may  be  able  to  carry  on  its  functions  in  a  relatively  nor- 
mal manner.     As  a  rule,  unless  inflammatory  changes  intervene, 


Fig.  86. — Chronic  diffuse  nephritis,  showing  diffuse  production  of  fibrous  connective  tis- 
sue with  replacement  of  the  glomeruli  and  many  large  hyaline  casts  in  the  tubules:  a.  a. 
Glomeruli  showing  fibroid  substitution  ;  b,  b,  diffuse  growth  of  connective  tissue  ;  c,  c,  hyaline 
casts  in  tubules. 

these  cases  do  not  terminate  fatally;  patients  so  afflicted  may 
pass  through  infectious  diseases  and  other  similar  processes  quite 
as  successfully  as  those  whose  kidneys  are  supposedly  normal. 


2o6  bright's  disease; 

Although  in  many  cases  the  kidney  manifestations  dominate 
the  disease-picture,  it  is  surprising  to  find  how  relatively  rare  it  is 
for  Bright's  disease  to  appear  as  an  independent  process.  As  has 
been  shown  elsewhere,  the  condition  commonly  originates  as  a 
result  of  some  other  disease  process,  and  in  its  chronic  as  well  as 
in  its  acute  form  the  most  important  guide  to  its  proper  under- 
standing and  treatment  lies,  not  in  the  consideration  of  the  kid- 
neys alone,  but  in  understanding  thoroughly  the  entire  system  and 
the  workings  of  quite  independent  viscera.  Thus  nearly  all  cases 
of  chronic,  and  many  of  acute,  Bright's  disease  are  associated 
with  serious  disturbances  of  the  vascular  apparatus.  So  inti- 
mately are  these  systems  functionally  associated  that  we  fre- 
quently now  speak  of  certain  forms  of  nephritis  as  vascular  renal 
or  cardiovascular  renal  complexes.  More  or  less  arteriosclerosis 
is  present  concomitantly,  and  in  the  inflammatory  forms  of  the 
disease  particularly  this  is  manifested  by  an  increase  in  the  general 
blood- pressure,  a  fact  that  is  well  recognized  of  considerable 
diagnostic  importance.  This  in  turn  leads  to  cardiac  hyper- 
trophy, myocarditis,  and  eventually  to  cardiac  dilatation,  incom- 
petence, and  secondary  circulatory  changes  in  the  brain,  liver,  and 
gastro-intestinal  tract — and,  finally,  in  practically  every  vital  organ 
of  the  body.  It  is  often  most  difiicult  to  determine  in  any  case  the 
order  or  sequence  of  these  changes.  Not  infrequently  it  seems  that 
the  renal  lesions,  although  dominating  the  case,  are  but  secondary, 
for  example,  to  arteriosclerosis,  myocarditis,  or  to  valvular  lesions 
of  the  heart  that  originally  led  to  renal  congestion.  This  but 
emphasizes  the  importance  of  considering  each  case  individually, 
and  of  treating  not  the  renal  lesion,  but  the  patient. 

THE   SYMPTOMS,  DIAGNOSIS,   COURSE,  AND  PROGNOSIS  OF 
BRIGHT'S  DISEASE 

In  acute  Bright's  disease  the  onset  is  frequently  sudden.  The 
patient  may  first  observe  that  the  amount  of  urine  is  diminished,  or 
that  the  ankles,  wrists,  or  face  become  swollen  at  times.  Not  un- 
commonly the  first  observed  symptom,  particularly  in  the  degenera- 
tive type,  is  an  enlarged  abdomen,  due  to  ascites.  In  a  small  num- 
ber of  cases  the  disease  is  inaugurated  with  a  chill,  and  may  be 
characterized  throughout  the  early  stages  by  a  mild  pyrexia;  this  is 


SYMPTOMS,    DIAGNOSIS,    COURSE,    AND   PROGNOSIS  207 

particularly  true  in  the  inflammatory  form.  The  pulse  is  rapid  and 
hard,  and  the  blood  pressure  is  considerably  raised,  although 
this  is  not  so  constant  in  the  cases  in  which  the  changes  are  chiefly 
of  a  degenerative  nature.  Sudden  dilatation  of  the  heart  may 
follow  this  raising  of  the  blood-pressure,  particularly  when  myo- 
carditis has  preexisted.  As  a  rule,  the  dropsy  is  somewhat  slight, 
in  the  acute  cases,  and,  instead  of  being  general,  it  is  oftentimes 
curiously  localized  to  certain  areas.  In  the  beginning  of  the 
disease  perspiration  is  generally  checked  and  the  skin  becomes 
harsh  and  dry.  Occasionally  the  onset  is  early  manifested  by 
the  occurrence  of  uremia,  and  active  maniacal  symptoms  or  con- 
vulsions may  develop,  to  be  succeeded  by  a  somnolent  or  coma- 
tose state.  These  uremic  symptoms  are  particularly  frequent 
in  acute  exacerbations  of  chronic  cases. 

The  amount  of  urine  is  greatly  diminished,  as  a  rule,  or  it  may 
become  entirely  suppressed.  It  is  usually  dark  in  color,  often 
smoky  from  the  presence  of  blood-pigment,  and  turbid  with  phos- 
phates, blood,  casts,  and  epithelial  cells.  The  specific  gravity  is 
generally  high,  although,  on  account  of  the  diminution  in  the 
amount  secreted,  the  total  solids  so  eUminated  are  also  diminished. 
Occasionally,  however,  the  amount  of  urea  present  is  normal. 
Albumin  generally  appears  in  large  amounts,  and  its  presence 
may  cause  a  lowering  of  the  specific  gravity.  The  quantity  is  no 
indication  of  the  gravity  of  the  case.  In  some  of  these  cases  the 
blood  nitrogen  is  markedly  increased,  but  we  believe  only  in  those 
instances  where  the  glomeruli  are  extensively  involved,  in  which 
instances  usually  the  urine  is  not  of  high,  but  of  persistently  low, 
specific  gravity. 

In  some  cases,  particularly  those  in  which  inflammatory  lesions 
predominate,  the  onset  is  marked  by  severe  pains  in  the  back, 
which  may  be  mistaken  for  those  of  a  myalgia.  Persistent 
nausea  or  vomiting  and  occasional  diarrhea  are  not  uncommon 
premonitory  or  initial  symptoms. 

Anemia  and  dyspnea  develop  early  in  the  course  of  the  disease. 
The  former  appears  to  be  due  not  so  much  to  the  actual  loss  of 
blood,  as  to  a  probable  hemolysis  taking  place  in  the  blood- 
stream as  a  result  of  excrementitious  substances  which  are  cir- 
culating in  this  tissue.     This  may  in  some  cases  give  rise  to  a 


2o8  BRIGHT'S   DISEASE 

pronounced  hemoglobinuria.  The  dyspnea  is  probably  due  to  a 
disturbed  CO2  coefficient,  or  possibly,  as  Fisher  asserts,  to  an 
acidosis. 

The  course  of  the  disease  depends  largely  on  the  general  con- 
dition of  the  patient,  and,  naturally,  on  the  degree  of  the  process, 
and  particularly  on  the  amount  of  urine  excreted,  the  amount  of 
retained  blood  nitrogen,  and  on  the  activity  of  the  subsidiary  ex- 
cretory organs. 

The  disease  is  easily  diagnosed,  but  it  is  not  so  easy  to  decide 
whether  the  condition  is  a  primary  or  a  secondary  manifestation. 
This  is  manifestly  a  most  important  matter,  since  if  the  process  be 
a  secondary  one,  relief  or  removal  of  the  cause  becomes  the  most 
essential  and  primary  factors  in  the  management  of  the  case. 

The  symptoms  may  be  confusing  and  the  diagnosis  of  chronic 
B right's  disease  is  made  with  much  greater  difficulty.  The  old 
theory  that  the  chemic  and  microscopic  examination  of  the  urine 
is  a  safe  guide  has  now  become  to  a  great  extent  obsolete,  nor  do 
blood  studies  always  clarify  the  situation  as  they  might  be  ex- 
pected to  do.  Although  it  is  possible,  within  proper  limitations, 
to  draw  valuable  information  from  such  aids  as  frequent  qualita- 
tive and  quantitative  examinations  of  the  urine  and  from  the 
phenolphthalein  or  Mosenthal  tests  as  to  permeability,  and  from 
the  use  of  the  sphygmomanometer,  still  absolute  diagnostic  evi- 
dence may  be  entirely  wanting  in  some  cases.  The  early  diagnosis 
of  so  insidious  a  disease  as  diffuse  interstitial  nephritis,  which 
causes  thousands  of  deaths  annually,  and  which,  according  to  sta- 
tistics, is  increasing,  is  a  feature  the  importance  of  which  the  pro- 
fession is  only  now  beginning  to  realize,  and  the  difficulty  and  un- 
certainty of  early  diagnoses  in  these  insidious  types  must  be  more 
fully  appreciated.  More  than  any  other  factor,  however,  in  these 
obscure  cases  studies  of  the  blood  chemistry  aid  us.  Recognized 
early,  either  as  a  primary  condition  or  as  the  result  of  some  pre- 
existing lesion  of  the  kidney  or  other  viscera,  much  can  be  done 
toward  arresting  the  disease  and  prolonging  the  life  and  usefulness 
of  the  individual. 

The  part  played  by  heredity,  as  shown  by  the  family  history 
of  the  patient,  may  or  may  not  be  of  importance.  Gout  seems 
to  be  hereditary  in  some  families,  and  is,  of  course,  a  frequent 


SYMPTOMS,    DIAGNOSIS,    COURSE,    AND   PROGNOSIS  209 

causative  factor  in  the  production  of  chronic  nephritis.  This  has 
been  newly  affirmed  by  studies  of  the  blood  viric  acid.  Inherited 
ner\^ous  weakness,  to  use  a  general  term,  seems  to  predispose  to 
the  development  of  an  early  interstitial  nephritis,  owing  to  the 
intimate  relationship  existing  between  the  nervous  system  and 
the  kidneys.  The  offspring  of  neurasthenic  parents,  it  might  be 
predicted,  would  have  kidneys  that  would  not  withstand  the 
strain  easily  borne  by  those  of  more  fortunate  ner^^ous  inheritance. 

More  important  than  the  family  history  is  the  personal  record 
of  the  patient — a  histor}^  of  the  occurrence  and  coiu-se  of  infectious 
or  venereal  diseases,  of  the  general  habits  of  life,  and  of  excesses  in 
drinking,  smoking,  or  eating.  Of  great  importance  in  this  respect 
— since  it  is,  the  writers  believe,  a  common  cause  of  nephritis — is 
the  presence  of  nerve-strain.  It  seems  to  be  the  general  opinion 
among  the  profession  as  well  as  among  the  laity  that  many  far-ad- 
vanced cases  of  Bright's  disease  remained  unrecognized  until  a  very 
short  time  before  death,  the  patients  suffering  no  discomfort  and 
complaining  of  no  symptoms.  This  has  not  been  borne  out  by  the 
writers'  clinical  experience,  which  shows  that  the  cases  of  chronic 
nephritis  that  have  not  presented,  long  before  death  occurred, 
symptoms  of  ill  health  apparent  to  an  intelligent  obser^^er,  are 
few  indeed.  Headache  is,  of  course,  a  common  symptom ;  it  may 
be  of  any  variety,  the  only  one  at  all  typical  being  the  intense 
general  orbital  distress  occasionally  met  in  patients  with  acute 
Bright's  disease  and  in  the  later  stages  of  the  chronic  form.  The 
ophthalmic  manifestations  have  been  discussed  in  a  previous 
chapter.  Indigestion  of  various  forms  is  very  commonly  com- 
plained of.  Sudden  attacks  of  vertigo  or  of  dyspnea,  without 
sufficient  accompanying  vigorous  physical  exercise  to  justify  its 
occurrence,  are  suspicious  symptoms.  The  symptoms  of  so-called 
cardiac  asthma  are  almost  pathognomonic  of  a  serious  renal  con- 
condition,  especially  if  unassociated  with  cardiac  arhythmias,  hy- 
pertrophy, or  other  explanatory  lesions  of  the  heart.  Arterio- 
sclerosis is,  in  its  mere  presence,  an  almost  certain  sign  of  more  or 
less  nephritic  disease,  especially  if  it  be  of  a  diffuse  form. 

The  condition  of  the  hair,  which  is  dry  and  brittle,  and  the 
state  of  the  skin,  which  may  be  the  seat  of  the  more  common 
forms  of  eruption,  such  as  the  many  varieties  of  eczema,  are 
14 


2IO  BRIGHT' S   DISEASE 

recognized  as  being  sometimes  associated  with  forms  of  renal 
insufficiency.  Pains  in  the  back  are,  by  the  laity,  often  attrib- 
uted to  kidney  lesions,  and  are  of  such  common  occurrence  in 
certain  cases  as  to  have,  the  writers  believe,  a  diagnostic  signifi- 
cance, although  oftentimes  entirely  wanting.  Edema  of  one  or 
both  of  the  lower  extremities,  transitory,  it  may  be,  can  be  de- 
tected on  examination;  or,  when  not  discovered,  a  history  of  its 
previous  existence  may  be  given. 

The  estimate  of  the  solids  of  the  twenty-four-hour  urine  is  of 
considerable  value.  If  this  is  found  permanently  below  70  grams 
daily,  and  if  no  other  explanation  for  it  exists, — as  an  unusual 
diet  or  a  deficient  amount  of  exercise, — a  suspicion  of  interstitial 
nephritis  may  be  entertained.  If  the  solids,  however,  run  habit- 
ually much  in  excess  of  this  amount,  it  denotes  that  the  kidneys 
are  being  overworked,  generally  as  the  result  of  overeating  or 
that  tissue  destruction  is  taking  place,  and,  when  by  appropriate 
manipulation  of  the  fluid  and  NaCl  intake,  concentration  of  the 
urine  does  not  take  place,  it  strongly  indicates  a  chronic  interstitial 
nephritis.  Albumin  and  casts  are  rarely  present  in  chronic  cases 
in  abundance  unless  an  acute  exacerbation  be  present.  Either 
may  be  present  without  the  other,  and  both  may  be  absent  for  long 
periods,  but  may  be  commonly  found  sooner  or  later  if  persistently 
searched  for.  The  significance  of  their  presence  or  absence  must 
not  be  overestimated.  In  cases  where  the  blood-pressure  is  found 
to  be  high  (in  the  neighborhood  of  190  mm.  or  more)  and  other 
causative  conditions  can  be  eliminated,  the  diagnosis  of  Bright's 
disease  can  often  safely  be  made,  whether  or  not  albumin  or  casts 
are  demonstrated  by  the  chemic  and  microscopic  examination  of 
the  urine.  Chemical  examination  of  the  tu-ine  for  retained  nitrog- 
enous bodies  in  abnormal  amounts  is  probably  our  most  certain 
diagnostic  sign,  though  by  no  means  infallible. 

Correct  prognosis  in  Bright  s  disease  can  be  given  only  after 
all  factors  have  been  considered.  Acute  Bright's  disease,  so 
far  as  immediate  danger  to  life  is  concerned,  ordinarily  presents 
a  fairly  good  prognosis  when  it  is  not  grafted  on  a  previously 
existing  chronic  condition.  It  often,  however,  leaves  as  a  sequel 
persistent  inflammation,  which  in  tm-n  may  set  up  a  fibrosis,  and 
the  various  forms  of  parenchymatous  and  other  acute  or  chronic 


SYMPTOMS,   DIAGNOSIS,    COURSE,    AND   PROGNOSIS  211 

degenerative  changes  may  ensue  with:  or  without  persistent  in- 
flammatory lesions.  The  prognosis  in  these  cases  is  dependent 
to  a  great  extent  on  the  amount  of  tissue  involved  and  on  whether 
one  or  both  kidneys  are  affected,  clinically  obvious  facts  most 
difficult  to  ascertain,  but  greatly  assisted  by  our  newer  methods 
of  study.  Although  definite  and  unmistakable  evidences  of 
persisting  renal  disease  maybe  present,  and  though  such  an  appli- 
cant is  immediately  rejected  by  life  insurance  companies,  he 
frequently  still  exhibits  a  fair  state  of  general  health,  and  may  live 
in  reasonable  activity  for  many  years. 

In  attempting  to  prognosticate  the  outcome  of  such  conditions, 
aid  may  be  obtained  from  ureteral  catheterization,  the  phenol- 
phthalein,  Mosenthal,  or  Albarran  tests,  and  the  like.  Generally, 
in  such  cases,  if  the  kidneys  and  other  excretory  organs  are  doing 
their  work,  if  the  retained  nitrogen  be  not  higher  nor  the  blood- 
pressin-e  greatly  elevated,  and  if  the  patient  can  be  kept  amid  good 
hygienic  siuroundings,  and  the  habits  of  life,  particularly  regarding 
diet,  can  be  approximately  regulated,  the  prognosis  is  fairly  good. 

When  a  diagnosis  of  chronic  interstitial  nephritis  is  made, 
and  it  is  found  that  the  kidneys  are  unable  to  eliminate  the  average 
amount  of  solids  in  twenty-four  hours,  and  that  a  persistent  blood- 
pressure  of  200  or  more  is  present,  the  prognosis  is  definitely  bad. 
If  general  edema  has  already  set  in,  in  almost  every  case  death 
ensues  within  a  few  months  at  the  latest.  When  the  blood-pressure 
in  such  cases  is  within  normal  limits,  but  not  indicative  of  a  failing 
circulatory  capability,  even  if  general  edema  has  already  ap- 
peared, the  prognosis,  although  extremely  grave,  is  not  so  serious. 
On  the  contrary,  when  the  pressure,  having  been  persistently  high, 
falls  suddenly  to  the  normal  or  below,  it  is  a  most  serious  prog- 
nostic sign  and  usually  precedes  death  by  but  a  short  time. 
Under  proper  treatment,  and  particularly  by  lessening  the  work 
of  the  kidneys,  some  chronic  nephritis  patients  may  live  for  years. 
The  correctness  of  the  prognosis  is  dependent  to  a  great  extent 
upon  the  accuracy  with  which  the  diagnosis  was  made;  as  has 
been  demonstrated,  this  cannot  be  formed  from  an  examina- 
tion of  the  urine  alone,  but  depends  more  largely  on  the  clinical 
picture  presented  by  the  entire  case,  and  especially  on  the  con- 
dition of  the  cardiovascular  apparatus. 


212  BRIGHT  S    DISEASE 

THE  TREATMENT  OF  NEPHRITIS 

There  is  no  more  severe  test  of  the  skill  of  the  physician  than  in 
the  management  of  cases  of  Bright's  disease.  In  no  class  of 
disorders  is  it  more  certain  that  each  case  must  be  treated  individ- 
ually, and,  therefore,  no  routine  method  of  treatment  can  safely 
be  adopted. 

It  is  particularly  important  in  the  care  of  nephritic  patients 
that  all  the  viscera  of  the  body  be  well  considered  in  each  step  of 
the  treatment,  for  interdependence  of  the  various  body  functions 
is  a  most  important  factor  in  this  group  of  diseases.  Furthermore, 
it  often  becomes  absolutely  necessary  to  change  the  entire  line  of 
treatment  in  a  case  that  may  have  progressed  favorably  up  to  a 
certain  point.  Continual  vigilance  is  imperative  if  the  best 
results  are  to  be  attained. 

Acute  Nephritis. — ^In  the  treatment  of  acute  nephritis  the  gen- 
eral or  non-medicinal  side  plays  a  very  essential  part.  The  pa 
tient  should  in  all  cases  be  ordered  to  bed,  preferably  clad  in  light 
woollen  sleeping  garments,  so  devised  that  they  may  be  changed 
or  removed  when  necessary  without  unduly  exposing  the  body. 
Night-gowns  that  open  at  the  side  or  in  front,  fastening  with  tapes 
instead  of  buttons^  have  been  found  very  convenient,  much  more 
so  than  pajamas.  The  sick-room  should  be  kept  at  a  uniform 
temperature  and  although  an  abundance  of  fresh  air  must  be 
insured,  the  patient  should  be  carefully  protected  from  sudden 
changes  and  shielded  from  drafts  that  may  suddenly  chill  the 
body.  It  has  been  found  advantageous  in  most  cases  to  keep 
the  room  temperature  somewhat  higher  than  is  required  in  most 
other  diseases— from  68°  to  72°  F.,  for  example. 

Not  only  is  mere  physical  rest  demanded,  but  absolute  mental 
quiet  is  also  most  essential.  To  insure  this,  visitors  should  gener- 
ally be  excluded,  at  least  in  the  early  and  critical  stages  of  the  dis- 
ease, and  only  those  should  be  allowed  to  see  the  patient  who,  it  is 
found,  have  a  good  effect  on  his  psychic  state.  The  patient  must 
especially  be  freed  from  business,  social,  and  particularly  domestic 
worry.  These  are  matters,  it  is  believed,  that  are  of  critical  value, . 
and  for  these  reasons  treatment  in  the  hospital  or  sanatorium  may 
be  found  much  more  successful  than  at  home. 


TREATMENT   OF   NEPHRITIS  213 

Symptomatic  treatment  must  be  instituted  from  the  outset. 
When  it  becomes  necessary  to  relieve  pain,  the  writers  prefer  to 
use,  for  this  purpose,  mechanic  rather  than  medicinal  measures^ 
when  the  former  can  be  made  to  suffice;  thus  cupping  or  the  ap- 
plication of  leeches  to  the  loins  often  gives  relief  from  the  severe 
backache  which  is  sometimes  a  prominent  symptom  of  the  dis- 
ease. When  necessary,  however,  the  writers  do  not  hesitate  to 
give  codein  or  morphin  in  small  doses,  or  when  a  mere  sedative  is 
demanded,  chloral  or  bromids,  in  small  amounts,  given  by  the  rec- 
tum, have  been  found  to  be  not  only  harmless,  but  actually  bene- 
ficial, not  only  in  quieting  pain  but  also  in  diminishing  nervous 
strain  or  worry,  in  producing  sleep,  and  oftentimes  in  reducing 
either  directly  or  indirectly  the  blood-pressure. 

The  diet  is  a  matter  of  paramount  importance.  Since  the  acute 
course  is  often  short,  and  since,  as  a  rule,  the  kidneys  are  already 
overworked,  there  should  be  no  hesitation  in  limiting  the  amount 
of  food  to  be  given  in  early  and  active  cases  to  the  minimum, 
even  as  little  as  600  calories  per  day  may  amply  suffice  for  periods 
of  several  days.  In  these  instances  the  only  food  should  be  milk 
and  cream  administered  in  quantities  of  from  i  to  1.5  liters. 
For  this  purpose  the  writers  prefer,  as  a  rule,  to  give  peptonized 
milk,  though  malted  milk,  buttermilk,  koumyss,  matzoon,  or  plain 
top-milk  may  be  preferred.  Although  they  do  not  approve  of  a 
strict  milk  diet  in  nephritis  of  any  grade  except  temporarily  in 
that  just  mentioned,  still  there  can  be  no  doubt  but  that  it  should 
form  the  basis  and  most  essential  portion  of  the  nephritic  diet. 
The  quantity  of  water  that  it  contains  is  in  some  cases  very  bene- 
ficial; in  others,  however,  this  fluid  is  positively  injurious,  as  it 
throws  too  great  a  strain  on  the  congested  and  overworked  organs 
and  the  amount  of  phosphoric  acid  and  of  albumins  may  be 
definitely  irritating.  Where  mere  calories  seem  needed,  lactose 
may  be  added  to  the  milk. 

We  frequently  also  employ  a  lemonade  or  other  fruit  juice  pre- 
pared of  1000  c.c.  of  water,  200  gm.  of  milk-sugar,  and  flavored  with 
fruit  juice  to  taste.  It  is  usually  grateful  to  the  patient,  absolutely 
non-irritating,  and  liberates  about  200  calories  of  food  value. 

Oatmeal,  arrowroot,  and  barley  gruels  are  acceptable  foods, 
and  they  may  be  given  with  cream,  which,  in  the  acute  phases  of 


214  bright's  disease 

nephritis,  the  writers  believe  to  be  beneficial,  especially  in  those 
cases  in  which  the  amount  of  other  food  allowed  is,  and  should  be, 
small. 

The  white  meats  may  not  be  contraindicated  except  in  actively 
acute  cases,  and  the  writers  have  frequently  used  them;  moreover, 
in  certain  cases,  especially  when  food  stimulation  seems  necessary, 
they  do  not  hesitate  to  employ  red  meat  in  small  amounts  or  ex- 
pressed meat-juice,  slightly  cooked,  and  given  with  some  digestive, 
when  the  experiment  shows  that  the  retained  blood  nitrogen  is 
not  thereby  increased.  The  writers  desire,  however,  to  warn  par- 
ticularly against  the  use  of  the  meat  extractives,  such  as  beef-tea, 
mutton  and  chicken  broths.  The  amount  of  nourishment  con- 
tained in  these  substances  is  relatively  small,  and  the  extractives 
that  make  up  the  greater  part  of  their  oxidizable  elements  are  often 
intensely  irritating  to  the  kidney. 

During  convalescence,  bread  and  butter,  toast,  milk-toastj 
green  vegetables,  spinach,  celery,  and  the  like  may  be  given. 
Fresh  and  stewed  fruits  and  unfermented  fruit- juices  are  very  ac- 
ceptable to  mpst  patients ;  they  do  no  harm  and  have  a  certain  nu- 
tritive value.  It  may  also  be  necessary,  in  this  stage  of  the  disease, 
to  give  more  freely  of  meat  and  other  nitrogenous  foods,  but  the 
return  to  a  normal  diet  must  be  made  slowly,  each  advance  being 
well  considered  before  being  undertaken,  especially  in  regard  to 
nitrogen-rich  substances. 

One  of  the  most  disputed  points  in  the  treatment  of  acute  ne- 
phritis lies  in  the  quantity  and  quality  of  water  to  be  drunk. 
Many  clinicians  advise  the  use  of  large  amounts  of  water,  even  in 
cases  where  the  tissues  are  soaked  with  edematous  fluid  and  where 
ascites  is  present.  The  water,  they  contend,  dilutes  the  poisons 
formed  by  the  disease,  promotes  the  activity  of  the  skin  and 
bowel,  and  finally  stimulates  diuresis.  There  can  be  no  question 
but  that,  in  occasional  instances,  the  free  drinking  of  water  is  a 
most  useful  measure,  especially  in  the  intensely  toxic  types  of 
the  disease.  The  writers  have  seen  many  cases,  however,  in  which 
it  resulted  in  increase  of  edema,  gastro-intestinal  disturbance, 
cardiovascular  failure,  and  aggravation  of  the  renal  disease. 
They  prescribe  water  in  excess  only  in  those  cases  in  which  edema 
is  not  present  and  in  which  the  toxic  manifestations  dominate  the 


TREATMENT   OF   NEPHRITIS  215 

disease-picture.  In  these  cases  careful  note  must  always  be 
made  of  the  liquid  intake  and  of  the  amount  excreted  with  the 
urine  and  feces,  and  if  it  is  found  that  any  considerable  portion 
of  the  water  is  being  retained,  or  if  the  amount  of  urinary  ex- 
cretion is  not  immediately  increased,  it  often  becomes  necessary 
to  go  to  the  opposite  extreme,  and  allow  only  such  small  quan- 
tities of  fluid  as  may  be  contained  in  the  food  or  as  may  be  neces- 
sary to  obviate  actual  suffering.  When  the  use  of  water  seems 
desirable,  the  writers  often  prescribe  it  in  the  form  of  the  no 
longer  fashionable  "hot  herb  tea,"  which  they  believe  exerts 
a  demulcent  action  that  is  frequently  of  considerable  benefit. 
Thus  they  employ  an  infusion  of  2  drams  of  violet  flowers  steeped 
for  about  five  minutes  in  a  pint  of  boiling  water — this  may  be 
given  two  or  three  times  daily;  besides  stimulating  diaphoresis 
and  diuresis,  this  infusion  sometimes  appears  to  act  also  as  a 
soporific.  Flaxseed  and  elder-flower  tea,  flavored  with  licorice 
root,  may  likewise  be  used  with  benefit.  Many  special  spring 
waters  are  particularly  recommended  by  some  physicians,  and 
if  one  were  to  believe  the  advertisements,  even  those  in  some 
reputable  medical  journals,  there  are  few  which  are  not  more  or 
less  curative  in  all  renal  disorders.  It  is  possible  that,  as  von 
Noorden  states,  those  containing  lime-salts  may,  through  their 
consequent  combination  with  the  phosphoric  acid  of  the  food, 
lessen  the  renal  irritation,  but  in  most  instances  they  are  either 
valueless  or  directly  harmful,  though  the  cathartic  action  of  cer- 
tain waters  may  be  really  beneficial.  Most  patients  return 
from  the  so-called  water  "cure"  worse  rather  than  better. 

Whether  water  be  given  in  large  or  small  amounts,  it  is  custo- 
mary for  the  writers  to  restrict  the  amount  of  NaCl  ingested, 
for  they  believe  that  this  substance  inevitably  throws  an  increased 
amount  of  work  on  the  kidney,  and,  by  concentrating  the  body- 
serum,  favors  dropsy.  Obviously,  all  renal  irritants,  such  as  the 
condiments,  are  contraindicated,  although  in  cases  in  which 
anuria  is  present,  minute  doses  of  tincture  of  cantharides  have 
been  advocated.  The  writers  have  never  obtained  good  results 
from  the  use  of  such  drugs,  and  they  also  condemn  the  indis- 
criminate use  of  most  diuretics,  with  the  exception  of  the  occa- 
sional employment  of  that  just  mentioned,  namely,  water. 


2l6  bright' S   DISEASE 

One  of  the  first  and  most  essential  steps  in  the  treatment  of 
acute  nephritis  consists  in  establishing  free  diaphoresis  and  cathar- 
sis. The  former  is  particularly  indicated  when  edema  or  dropsy 
is  present.  In  the  writers'  opinion,  diaphoresis  is  best  stimulated 
by  the  use  of  the  hot-pack,  thermo-electric  bath,  or  the  employ- 
ment of  dry  heat.  When  either  of  these  measures  is  used,  atten- 
tion must  be  paid  to  the  action  of  the  heart,  and  not  infrequently, 
in  cases  of  anuria,  diuresis  as  well  as  diaphoresis  may  be  satis- 
factorily established  simply  by  regulating  the  circulatory  appa- 
ratus. Aconite  may  be  employed  with  advantage  when  over- 
activity of  the  heart  exists,  and  sometimes,  particularly  in  the 
degenerative  type  of  nephritis,  digitalis  or  one  of  the  preparations 
of  strophanthus  may  be  used.  We  rarely  prescribe  these  drugs,  how- 
ever, except  where  definite  circulatory  disturbances  are  manifest. 

The  results  following  the  use  of  pilocarpin  to  stinmlate  diapho- 
resis has  not  justified  its  recommendation,  except  as  an  extreme 
measure. 

Catharsis  is  best  promoted  by  the  preliminary  use  of  calomel  in 
those  cases  in  which  internal  medication  is  not  contraindicated. 
Jalap  and  elaterium  have  an  excellent  effect  at  times,  and  the 
concentrated  solutions  of  magnesium  sulphate,  either  given  by 
the  mouth  or  used  as  an  enema,  generally  prove  most  satisfactory. 

In  the  presence  of  coma,  elaterium,  jaborandi,  and  pilocarpin 
may  be  necessary,  but  even  here  the  greatest  reliance  is  to  be 
placed  on  the  hot  pack  or  on  the  hot-air  treatment,  on  stimula- 
tion of  the  heart  when  necessary,  and  on  the  maintenance  of  free 
catharsis.  Bleeding  often  is  of  the  greatest  possible  benefit  in 
such  cases,  and  where  edema  is  not  present  and  toxemia  is  marked, 
saline  infusions  may  appropriately  follow. 

In  those  cases  in  which  effusions  of  serum  into  the  pleural  and 
peritoneal  cavities  exist,  the  writers  believe  the  proper  treat- 
ment to  consist  of  early  and,  if  necessary,  frequent  aspiration; 
the  same  measure — that  is,  puncture  and  occasionally  the  use  of 
cannulas — may  also  be  employed  in  those  cases  in  which  excessive 
edema  of  the  extremities  is  present.  Particular  care  must  be 
exercised  to  guard  against  infection.  Pulmonary  edema  may  be 
treated  by  cupping  or  by  the  use  of  atropin  and  cardiac  stimulants. 

Throughout  the  entire  course  of  the  disease  symptomatic  treat- 


TREATMENT   OF   NEPHRITIS  217 

ment  is  constantly  necessary,  but,  whenever  possible,  drugs 
should  be  avoided,  since  they  have  a  tendency,  in  most  cases, 
to  increase  the  work  of  the  kidneys  without  corresponding  relief. 
Care  directed  to  the  action  and  conservation  of  the  heart  and 
vascular  apparatus  is  secondary  in  importance  only  to  that  of 
the  kidney  itself;  acute  dilatation  of  the  heart  must  be  looked  for 
and  guarded  against;  excessive  blood-pressure  must  be  detected 
and  relieved — which  is  best  accomplished  by  phlebotomy  or  by 
the  temporary  use  of  the  nitrites,  nitroglycerin,  or  sometimes  by 
chloral;  and,  on  the  other  hand,  sudden  or  marked  decrease  in  the 
blood-pressure  must  be  looked  for,  and,  if  possible,  prevented. 

The  management  of  the  convalescence  of  acute  nephritis  applies 
practicallv  to  the  early  treatment  of  chronic  nephritis,  since  all, 
or  nearly  all,  attacks  of  acute  nephritis  leave  in  the  kidney  cer- 
tain inflammatory  or  degenerative  lesions  that  persist  for  months 
after  the  acute  symptoms  of  the  disease  have  disappeared,  but 
which  must,  nevertheless,  be  constantly  borne  in  mind  by  the 
discreet  clinician. 

The  Treatment  of  Chronic  Bright 's  Disease. — The  medicinal 
treatment  of  chronic  nephritis  has  been  sufficiently  considered 
under  the  head  of  the  active  treatment  of  acute  t3^pes  of  the 
disease,  for  in  the  chronic  form,  as  a  rule,  little  or  no  medication 
is  required  except  when  symptoms  of  a  subacute  nature  arise  or 
acute  exacerbations  appear.  Such  instances  are  to  be  managed 
precisely  as  in  the  acute  disease  in  so  far  as  the  use  of  drugs  and 
general  therapeutic  measures  are  concerned.  As  a  matter  of  fact, 
active  manifestations  in  the  chronic  course  differ  but  little  from 
the  acute  disease  except  that,  as  a  rule,  the  prognosis  is  not  so  good 
and  response  to  treatment  is  rather  less  rapid.  The  sooner  thera- 
peutic measures  are  resorted  to,  the  more  favorable  the  prognosis 
and  the  earlier  restoration  to  health,  or  rather  to  comparative 
health,  for  it  must  be  remembered  that  in  chronic  nephritis  the 
lesions  inflicted  on  the  kidney  are  essentially  of  a  permanent  char- 
acter, though  clinical  recovery  is,  of  course,  by  no  means  rare. 

The  most  important  phase  of  the  management  of  cases  of  chronic 
Bright's  disease,  either  of  the  degenerative  or  interstitial  type,  is 
the  prophylactic  measures  employed,  as  a  result  of  which  acute  or 
subacute  symptoms  are   obviated   and  the  progress  of  the  dis- 


2l8  BRIGHT'S  DISEASE 

ease  becomes  checked.  A  most  careful  study  of  the  patient,  and 
particularly  of  his  relationship  to  his  surroundings,  is  therefore 
absolutely  essential.  Only  the  most  general  rules  can  be  laid 
down  in  this  regard,  for  not  only  does  each  case  differ  in  itself, 
but  also  in  the  necessary  conditions  of  life  which  surround  it. 
These  latter  often  determine,  even  more  than  the  actual  ana- 
tomic lesion,  the  course  of  the  case,  and  successful  treatment, 
therefore,  presupposes  a  thorough  study  of  the  individual  and 
his  obligations. 

Personal  Hygiene. — One  of  the  most  serious  matters  of  per- 
sonal hygiene  is  the  selection  of  occupation.  In  most  cases  we 
find  in  this  regard  that  necessity  lays  down  rules  over  which  the 
physician  may  not  trespass,  but  in  nearly  all  cases,  even  the  most 
unfavorable,  ameliorating  conditions  may  be  so  introduced  as  to 
work  great  relief  to  the  patient  without  the  ruin  of  his  business 
prospects.  The  hours  for  work  should,  if  possible,  be  limited; 
this  is,  in  our  opinion,  more  necessary  for  professional  men  than 
for  the  laboring  and  business  classes,  on  account  of  the  demand 
for  emergency  work  and  great  nervous  strain  coupled  with  most 
professional  vocations.  Good  ventilation  of  the  office  or  work- 
room is  important,  and  the  air  must  be  freed  in  so  far  as  possible 
from  dust  and  any  irritating  gases,  for  the  importance  of  healthy 
pulmonary  excretion  is  universally  recognized  for  all  cases  of 
crippled  kidneys.  Sunlight  is  also  desirable,  and  obviously  work 
by  day  is  more  advisable  than  night  occupation.  Work  in  damp, 
dark  basements  or  in  improperly  warmed  quarters  is  very  dele- 
terious, and  these  are  conditions  which  we  find  very  often  asso- 
ciated with  the  most  serious  types  of  the  disease  as  we  see  it, 
particularly  in  the  great  cities. 

Occupations  which  are  in  themselves  dangerous  for  the  renal 
function  must  be  given  up ;  such  as,  for  example,  in  chemical  works 
or  factories  where  absorption  of  irritating  substances  may  occur, 
the  excretion  of  which  excites  renal  disease.  Excitement  and 
nervous  strain  are  to  be  eliminated  in  so  far  as  possible;  worry 
is  in  itself  one  of  the  most  common  productive  factors  of  chronic 
nephritis,  and  the  patient  must  be,  therefore,  relieved  in  this 
respect. 

The  clothing  should  not  be  too  heavy,  but  it  should  be  suffi- 


TREATMENT   OF   NEPHRITIS  219 

cient  for  requisite  protection  of  the  body.  Extremes  of  heat  or 
cold  imposed  by  cUmatic  necessities  should  in  all  cases  be  prop- 
erly considered  in  the  choice  of  clothing.  As  a  rule,  we  have 
found  that  light  wools  are  best  for  the  undergarments,  even  for 
summer  wear,  and  in  all  climates,  even  in  the  tropics,  for  night 
use.     Silk  may  be  also  so  worn. 

The  outer  clothing  should  be  selected  with  direct  reference 
to  the  climatic  conditions.  In  the  temperate  climates  light 
wools  of  medium  grade  should  be  selected  according  to  the  season, 
and  in  the  tropics  linen  or  cotton  is  commonly  desirable.  Over- 
coats should  always  be  at  hand  where  sudden  changes  in  the  tem- 
perature or  humidity  are  to  be  expected,  and  the  patient  must 
avoid  chilUng  of  the  body  surface. 

The  question  of  baths  is  a  most  important  one,  and  is  to  a  large 
degree  determined  by  the  condition  of  the  circulatory  system  of 
the  patient.  When  no  contraindications  exist,  frequent  warm 
or  even  hot  baths  are  desirable,  so  that  the  skin  may  be  kept  free 
and  clean  with  its  excretory  possibiHties  at  the  maximum.  Hot 
baths  should  not  be  taken  except  immediately  before  going  to  bed 
or  if  they  be  terminated  by  gradual  transition  to  cold  water  of  a 
temperature  not  over  that  of  the  outside  air.  Except  in  the  case 
of  stout  persons  'where  the  cardiac  condition  is  excellent,  we  do  not 
advise  the  Turkish  bath,  and  we  consider  it  a  dangerous  proce- 
dure in  a  very  large  number  of  cases,  especially  where  the  heart 
is  in  doubtful  condition.  The  same  effects  may  be  safely  achieved 
by  the  hot  pack,  which  may  be  given  at  regular  intervals  in 
appropriate  cases.  We  do  not  recommend  the  cold  plunge, 
although  there  may  be  instances  where  good  reaction  follows  and 
in  which  the  observation  of  the  individual  case  demonstrates 
that  it  is  beneficial.  The  spray,  shower,  or  needle  bath  as  a 
general  thing  possesses  all  the  stimulating  effects  of  the  plunge 
without  the  sudden  and  often  dangerous  shock. 

Massage  is  a  very  beneficial  measure,  especially  for  patients  of 
sedentary  habit.  Properly  administered,  it  stimulates  the  periph- 
eral circulation,  improves  the  excretory  powers  of  the  skin,  and 
keeps  the  skeletal  muscles  in  good  tone.  It  is  not  and  cannot 
become  a  satisfactory  substitute  for  actual  physical  exercise, 
though  it  may  be  a  very  convenient  makeshift,  especially  for  bed- 


222  BRIGHT' S   DISEASE 

generalities,  but  entirely  on  the  effect  in  the  individual  case. 
Generally  from  3000  to  4000  calories  per  day  should  suffice,  and 
in  our  experiences  outside  of  the  hospital  the  tendency  has  been 
rather  to  over-  than  to  underfeed. 

Condiments,  such  as  pepper  and  the  highly  spiced  sauces,  must, 
of  course,  be  excluded.  Alcohol  is  never  to  be  taken  except  in 
small  amounts  or  when  the  drug  is  needed  for  its  therapeutic 
effect.  Some  cases,  however,  when  habituated  to  alcohol  lose 
ground  when  entirely  deprived  of  it,  and,  properly  administered, 
it  may  be  but  slightly  or  not  at  all  irritating  to  the  kidneys. 
Coffee  and  tea  may  be  temperately  used  in  most  cases  to  good 
advantage.  Where  coffee  overs timulates,  the  brands  largely 
freed  from  caffein  may  be  given. 

The  amount  of  water  demanded  depends  largely  on  the  rate 
of  excretion  in  the  urine,  on  diaphoresis,  and  on  the  effects  on 
the  vascular  organs.  As  a  rule,  it  should  be  less  rather  than  too 
large,  particularly  in  interstitial  cases.  Salt  is  always  to  be  cur- 
tailed, especially  for  those  who  normally  desire  large  amounts  of 
this  chemical  or  where  edema  is  present.  In  cases  associated 
with  gout  and  rheumatism  it  will,  however,  be  found  necessary  to 
be  more  liberal  in  the  use  of  water,  and  in  practically  all  cases 
the  occasional  copious  use  of  water,  as  suggested  by  von  Noorden, 
is  beneficial. 

Decortication  of  the  kidney  is  discussed  under  the  Surgery  of 
the  Kidney.     We  do  not  advise  it  in  any  case. 

Cases  of  chronic  B right's  disease  should  always  be  kept  under 
frequent  observation.  Very  careful  supervision  of  diet  is  necessary 
as  long  as  life  exists.  Timely  symptomatic  use  of  drugs,  of  the 
diuretics,  diaphoretics,  saline  cathartics,  and  a  carefully  regulated 
life  usually  so  benefit  that  the  disease  may  no  longer  be  thought 
inconsistent  with  a  long  and  relatively  active  life. 


CHAPTER  X 

UREMIA 

Inasmuch  as  uremia  occasionally  occurs  independent  of  clini- 
cally recognizable  Bright's  disease,  it  has  seemed  well  to  the 
writers  to  discuss  it  as  though  it  were  a  disease  entity. 

Because  of  the  obscurity  of  the  pathologic  conditions  under- 
lying uremia  it  is  deemed  advisable  first  to  consider  the  disease 
from  its  clinical  aspects. 

For  our  purposes  Osier's  classification  of  the  disease  by  its 
symptoms  will  be  adopted  with  a  few  modifications,  and  it  will 
be  discussed  under  the  headings  of  cerebral,  dyspneic,  gastro- 
intestinal, and  renal  types. 

The  most  striking  symptoms  of  uremia  are  those  of  cerebral 
origin.  Of  these,  a  more  or  less  active  mania  is  most  commonly 
seen;  this  may  manifest  itself  in  talkatiA'eness,  w^hich  is  generally 
illogical  and  rambling,  in  marked  physical  and  mental  restlessness, 
with  insomnia,  and  sometimes  by  active  emotional  delirium, 
persistent  hallucinations,  or  perhaps  melancholic  delusions.  All 
these  abnormal  manifestations  closely  resemble  those  seen  in 
many  cases  of  acute  alcoholism,  and  very  often  closely  approximate 
the  Korsakoff  syndrome. 

Convulsive  seizures  are  common,  and  not  infrequently  resemble 
those  characterizing  mild  attacks  of  Jacksonian  epilepsy;  there 
may  be  sudden  loss  and  as  sudden  recovery  of  vision,  or  con- 
vulsive attacks  of  projectile  vomiting  may  occur.  The  breath 
often  becomes  almost  ammoniacal  in  odor,  and  the  assertions  of 
older  clinicians  that  the  condition  may  be  detected  from  the  odor 
given  out  by  the  patient  is  sometimes  confirmed. 

Coma  is  one  of  the  most  familiar  of  the  cerebral  evidences  of 
uremia.  It  may  amount  simply  to  sleepiness  or  torpor  of  longer 
or  shorter  duration.  Great  difficulty  will  be  experienced  in 
distinguishing  this  particular  type  of  the  disease  from  alcoholism, 
but  in  this  regard  it  must  always  be  borne  in  mind  that  true 

223 


224  UREMIA 

uremia  frequently  appears  as  a  terminal  complication  of  alcohol- 
ism. 

The  knee-jerks,  at  first  usually  excited,  commonly  are  lost  toward 
the  end,  and  almost  always  the  Babinski  reflex  or  the  Oppenheim,  or 
both,  become  positive  a  considerable  time  before  death  impends. 
Tremors  of  a  fine  type  are  frequently  seen. 

Local  palsies  are  very  common  in  uremia,  and  many  cases  are 
seen  presenting  first  symptoms  quite  typical  of  hemiglegia  or 
of  paralysis  of  individual  muscles  or  groups  of  muscles.  Ordi- 
narily, such  cases  are  easily  distinguished  from  those  of  actual 
paralysis  by  the  incoherence  of  the  symptoms  and  by  their  evanes- 
cent character,  as  well  as  by  the  presence  of  manifestations 
of  renal  insufficiency — points  of  paramount  value  in  the  differ- 
ential diagnosis  of  all  types  of  uremia.  Cases  diagnosed  as 
cerebral  hemorrhage  or  embolism  are  often  found  on  postmortem 
examination  to  have  been  purely  uremic. 

The  patients  presenting  respiratory  sympto'ms  show  in  the 
milder  cases  paroxysmal  or  alternating  dyspnea,  and  in  the  more 
severe  cases  the  breathing  takes  on  the  character  of  the  Cheyne- 
Stokes  respiration.  These  symptoms  are  apparently  due  to  a 
disturbed  CO2  coefficient. 

The  most  common  gastro-intestinal  symptom  is  nausea,  which 
is  often  very  persistent,  and  is  sometimes  accompanied  by  pro- 
pulsive vomiting,  as  in  cerebral  tumor.  Diarrhea  is  also  a  frequent 
symptom,  but  probably  occurs  only  as  an  effort  at  compensatory 
excretion  on  the  part  of  the  bowel.  For  the  same  reason,  pro- 
fuse sweating  is  often  a  marked  symptom,  and  occasionally,  the 
perspiration  is  loaded  with  urea  and  other  excrementitious 
products. 

The  kidney  manifestations  usually  present  in  uremia  may  be 
summarized  as  those  of  decreased  renal  activity,  generally  shown 
by  a  relative  decrease  in  the  amount  of  solids,  and  particularly 
in  the  amount  of  urea,  excreted.  Often  the  symptoms  of  active 
renal  disease  accompany  these  indications  of  renal  inactivity, 
and  albumin,  casts,  blood,  and  desquamated  epithelium  appear 
in  the  urine.     Acute  suppression  is  quite  frequent. 

Although  it  is  generally  admitted  that  uremia  is  a  condition 
dependent  on  disease  or  inactivity  of  the  kidney,  the  pathologic 


UREMIA  225 

conditions  that  produce  this  inactivity  are  obsciu-e.  Uremia  oc- 
curs not  so  very  rarely  when  the  quantity  of  urine  excreted  is  nor- 
mal, and  when  the  urea  and  other  solids  are  still  apparently  in 
normal  relation.  We  are  therefore  forced  to  the  conclusion  that 
in  these  instances  the  condition  may  exist  without  evident  renal 
disease.  In  this  regard  it  should  be  borne  in  mind  that  the  state 
of  the  urine  is  by  no  means  always  a  positive  determinative  test 
of  the  actual  condition  of  the  kidneys.  Nevertheless,  it  is  gener- 
ally conceded  that  uremia  is  due  in  all  cases  to  the  presence  of 
renal  lesions,  and  it  remains  for  us  to  determine  the  manner  in 
which  renal  insufficiency  may  declare  itself.  Uremia  is  generally 
regarded  as  the  result  of  some  form  of  poisoning,  dependent  on 
deficient  excretion,  by  the  kidneys,  of  toxins  formed  in  the  course 
of  tissue  metabolism. 

The  earliest  belief  was  that  the  condition  was  caused  by  the 
presence,  in  the  blood,  of  an  abnormally  large  amount  of  urea, 
which  should  have  been  excreted  from  the  body  by  the  action  of 
the  kidneys.  As  a  matter  of  fact,  the  blood  in  uremia  usually 
does  contain  an  abnormally  high  percentage  of  urea ;  exceptional 
cases  are  met,  however,  in  which  the  amount  of  urea  present  in 
the  blood  has  not  increased  when  uremic  symptoms  manifested 
themselves.  Cases  also  occur  in  which  there  is  an  excessive 
amount  of  urea  in  the  blood  without  the  development  of  uremia, 
so  that  although  urea  is  usually  present  in  large  amounts  in  the 
blood  and  tissues  of  uremic  subjects,  this  is  not  invariably  the 
rule,  and  the  disease  may  arise  without  any  abnormal  increase. 
Again,  recent  study  has  tended  to  confirm  the  old  idea  that  uremia 
is  or  may  be  truly  a  poisoning  from  the  retention  of  urea  in  the  blood. 

The  preponderant  experimental  evidence  .has,  however,  ap- 
parently proved  that  the  introduction  of  urea  into  the  circulation 
is  not  productive  of  uremic  symptoms;  if,  however,  this  is  com- 
plicated by  injuries  to  the  renal  tissues,  some  experimenters  have 
asserted  that  symptoms  resembling  those  of  uremia  are  produced. 
This  statement  has  not  received  sufl&cient  corroboration  to  justify 
absolute  acceptance.  Urea  is  used  in  the  treatment  of  disease, 
especially  as  a  diuretic,  and  it  is  quite  certain,  from  abundant 
experience,  that  the  condition  is  not  due  simply  to  the  presence  of 
urea  in  the  blood. 
IS 


226  UREMIA 

The  next  and  most  natural  supposition  is  that  the  poison  of 
uremia  (for  the  condition  is  cUnically  a  toxemia)  is  due  to  the 
formation,  in  the  blood,  of  bodies  allied  to,  or  derived  from,  urea. 
Frerichs  promulgated  the  theory  that  it  was  due  to  the  presence 
of  ammonium  carbonate,  which  was  formed  in  the  blood  as  the 
result  of  fermentation,  which  had  resulted  in  disintegration  of 
the  urea  molecule.  This  seemed  for  a  time  to  adequately  explain 
the  symptomatology,  but  later  investigations  showed  that  ammo- 
nium carbonate,  when  introduced  into  the  blood,  does  not  pro- 
duce the  symptoms  of  uremia,  even  when,  in  addition,  the  kidney 
tissue  is  subjected  to  traumatism  and  normal  excretion  is  prevented. 

The  next  supposition  advanced  was  that  the  symptoms  were 
caused  chiefly  by  other,  perhaps  unrecognizable,  excrementitious 
products  in  the  blood.  Investigations  have  also  failed  to  demon- 
strate this  satisfactorily,  for,  as  has  previously  been  stated,  the 
symptoms  occasionally  arise  in  those  cases  in  which  the  urine 
and  blood  themselves  are  normal.  It  must  be  remembered,  in. 
this  connection,  that  information  regarding  the  exact  nature  of 
all  these  bodies  is  still  wanting,  and  our  knowledge  of  the  chemis' 
try  of  the  blood  and  urine  is  not  sufficiently  complete  to  warrant 
us  in  discrediting  the  foregoing  statement.  The  fact  that  we 
have  as  yet  been  unable  to  demonstrate  its  truth  by  no  means 
disproves  its  possibility. 

The  recent  studies  of  the  blood  which  show  in  most,  but  not  all, 
cases  of  clinical  m-emia  that  the  amount  of  filterable  nitrogenous 
bodies  retained  in  the  blood,  often  four  to  ten  times  the  normal, 
may  possibly  represent  such  poisons.  In  some  of  our  personal 
observations,  however,  typical  clinical  cases  of  uremia  have  shown 
no  increase  in  these  elements  in  the  blood,  and  while  there  can  be 
no  question  whatever  that  we  are  now  much  nearer  to  the  solution 
of  this  problem,  it  is  as  yet  by  no  means  solved. 

Osier  holds  that  interference  with  the  renal  functions  leads  to 
a  disturbance  of  the  regular  chemic  changes  in  all  parts  of  the 
body;  such  a  change  is  followed  by  alteration  in  the  nutrition  of 
the  tissue,  showing  itself  in  a  loss  of  weight,  in  anemia,  and  in 
cerebral  disturbances.  This  theory  is  so  indefinite  and  broad  as 
to  be  of  no  aid  to  us  in  explaining  the  cause  or  the  course  of  the 
disease,  nor  is  it  substantiated  by  clinical  or  by  experimental 
evidence. 


UREMIA  227 

Traube  has  presented  a  theory  that  the  symptoms  are  really 
due  to  morphologic  lesions  and  not  to  chemic  toxemia.  He 
asserts  that  interference  with  the  renal  functions,  which  all  admit 
-is  at  the  origin  or  root  of  the  disease,  leads  to  a  thinning  of  the 
blood-serum,  to  hypertrophy  of  the  left  ventricle  of  the  heart, 
and  to  excess  of  arterial  pressure.  Now,  if  by  any  accident  or 
circumstance  the  pressure  is  increased  still  more  and  the  serum 
still  further  thinned,  anemia  and  edema  of  the  brain  follow,  caus- 
ing various  uremic  manifestations,  according  as  certain  portions 
of  the  central  nervous  organs  become  affected.  This  theory  is 
founded  on  the  assertion  that  the  blood  pressure  is  always  in- 
ceased  in  uremia, — a  statement  that  is  not  invariably  true, — 
and  that  the  specific  gravity  of  the  blood-serum  is  always  dimin- 
ished— a  statement  that  is  Hkewise  not  invariably,  although 
it  is  generally,  true.  Further,  it  is  stated  that  anemia  and  edema 
of  the  brain  are  not  always  present.  Personally,  the  writers  are 
inclined  to  accept,  to  a  certain  extent,  this  theory,  in  so  far  as 
the  symptomatology  is  concerned,  for  in  their  own  cases  they 
have  found  that  a  localized  edema  and  anemia  of  the  brain  is 
generally  present ;  and  they  know  that  in  other  similar  conditions, 
symptoms  resembling  those  of  uremia  are  induced  by  cerebral 
edema,  but  we  also  believe  that  these  changes  are  induced  by 
chemical  toxins  in  some  way  dependent  primarily  on  renal  lesions. 

Stengel  advances  the  theory  that  the  degenerated  cells  of  the 
kidney  may  in  themselves  liberate  a  poison  that  acts  on  the 
brain-cells  in  the  manner  indicated  by  the  symptoms  of  the  disease ; 
this  is  the  theory  of  the  formation  of  the  nephrotoxins.  There  is 
no  absolute  data  on  which  this  theory  is  based — it  is  purely  specu- 
lative. 

In  certain  types  of  uremia  we  are  unable  to  demonstrate  at 
postmortem  any  lesions  in  the  kidney  to  account  for  the  symp= 
toms;  for  example,  in  the  marked  toxic  uremia  that  takes  place 
during  pregnancy  and  puerperal  eclampsia  no  changes  may  be 
found  (Delafield) .  Of  course,  it  is  possible  that  our  methods  are  not 
sufficiently  accurate  to  enable  us  to  detect  all  important  changes 
that  may,  nevertheless,  be  present,  but,  notwithstanding  this, 
it  must  be  admitted  that  certain  classes  of  cases  arise  in  which 
the  explanation  founded  on  the  basis  of  pure  kidney  lesions  is 


2  28  UREMIA 

inadequate.  In  this  relation  it  is  well  to  consider  the  possibility 
of  the  toxin  being  other  than  of  renal  origin.  Its  absence  in  purely 
traumatic  or  quantitative  kidney  lesions  is  of  much  significance, 
and  it  seems  opportune  here  to  review  briefly  some  of  the  experi- 
mental work  on  uremia  in  which  ablation  of  kidney  tissue  has  been 
performed. 

It  has  been  found  that  when  both  kidneys  are  removed  or  totally 
destroyed  by  disease  life  lasts  seven  to  fourteen  days.  The  chief 
symptoms  observed  in  these  cases,  aside,  of  course,  from  complete 
anuria,  are  contraction  of  the  pupils,  muscular  weakness,  and  sub- 
normal temperature;  severe  vomiting  is  occasionally  observed. 
There  is  no  loss  of  consciousness,  and  the  convulsions  so  charac- 
teristic of  uremia  are  not  present.  Hence  we  find  that  uremia 
is  not  typified  by  the  same  symptoms  that  follow  complete  absence 
of  renal  tissue. 

Again  the  question  arises  as  to  the  possibility  of  uremia  develop- 
ing when  a  portion  of  the  kidney  substance  is  removed — an 
experimental  condition  that  much  more  closely  approximates 
those  found  in  most  diseased  states.  According  to  Bradford, 
the  only  effect  noted  if  part  of  one  kidney  is  removed  is  an  increase 
in  the  amount  of  water  secreted;  no  general  symptoms  appear. 
If,  in  addition  to  the  first  operation,  the  other  kidney  is  afterward 
entirely  removed,  there  is  a  persistent  and  great  increase  in  the 
amount  of  water  secreted,  but  no  other  symptoms  arise  if  one- 
third  of  the  normal  kidney  weight  remains.  Removal  of  three- 
fourths  of  the  kidney  weight  proves  fatal,  and  the  subject  dies, 
greatly  emaciated,  diarrhea  and  subnormal  temperature  being 
occasionally  observed  as  symptoms;  there  is  a  great  accumula- 
tion of  urea  in  the  blood  and  in  the  body  tissues,  and  this  probably 
accounts  for  the  polyuria.  Coma,  convulsions,  and  all  other 
symptoms  typical  of  uremia  are  entirely  wanting.  Thus  it  may 
be  seen  that  uremia  is  apparently  not  due  to  a  decrease  in  the 
volume  of  functionating  kidney  tissue ;  neither  does  it  seem  to  be 
due  to  the  presence  of  urea  and  allied  bodies  in  the  blood  and  tissue 
of  the  body,  even  when  this  surplus  urea  is  formed  by  the  body-cells 
in  the  normal  manner  and  is  not  introduced  artificially. 

Lesions  of  the  Kidneys  Present  in  Uremia. — Uremia  frequently 
occurs  as  the  immediate  cause  of  death  in  scarlatinal  nephritis, 


UREMIA  229 

in  pneumonia,  and  in  similar  acute  infectious  diseases;  it  is 
also  seen  as  a  sequel  to  alcoholism.  In  both  infectious  diseases 
and  in  acute  alcoholism  it  is  associated  with  the  lesions  of  acute 
diffuse  nephritis,  which,  arising  from  any  cause  whatever,  are 
very  commonly  followed  by  uremia.  Uremia  may  further  be 
looked  upon  as  the  ordinary  terminal  condition  in  chronic  intersti- 
tial nephritis,  especially  in  that  variety  in  which  the  small  sclerotic 
kidney  is  found ;  thus  it  may  be  seen  in  cases  of  chronic  alcoholism, 
in  lead  poisoning,  and  in  gout.  It  also  occurs,  although  somewhat 
less  frequently,  in  those  cases  in  which  a  chronic  interstitial 
hyperplasia  has  taken  place,  as  in  chronic  diffuse  nephritis  of  the 
interstitial  type.  It  arises  in  all  the  degenerative,  particularly 
in  all  the  chronic  degenerative,  processes,  as  in  long-standing 
amyloid  degeneration,  and  especially  in  those  long-standing  cases 
in  which  an  acute  complication  or  exacerbation  intervenes. 

On  the  other  hand,  as  would  commonly  be  inferred  from  the 
experiments  cited,  uremia  should  not  occur  in  such  lesions  as 
pyonephrosis,  renal  calculus,  hydronephrosis,  nor  in  those  changes 
that  are  characterized  by  more  or  less  simple  destruction  of  renal 
tissue. 

The  experiments  of  Bouchard  and  of  others  have  shown  that 
normal  urine,  when  experimentally  introduced  into  animals, 
possesses  a  more  or  less  constant  and  definite  degree  of  toxicity. 
Other  investigations,  founded  on  those  just  mentioned,  have  also 
shown  that  this  degree  of  toxicity  varies  in  different  diseases  in  a 
degree  almost  constant,  being  increased  in  certain  conditions,  as 
in  various  infectious  processes,  and  decreased  in  others,  notably  in 
uremia.  These  observations  apparently  indicate  that  in  uremia 
certain  toxins  are  either  not  formed  at  all  or,  if  formed,  are  not 
eliminated,  but  retained  in  the  tissues  of  the  body.  This  may  be 
construed  to  mean  that  in  uremia  these  toxic  bodies  may  be 
responsible  for  the  typical  toxic  symptoms.  As  is  at  once  apparent, 
our  more  recent  knowledge  of  the  usual  blood  chemistry  in  uremia 
tends  to  substantiate  this  concept.  Ablation  experiments  seem 
to  show  that  these  specific  toxins  are  not  formed  nor  retained 
when  morphologic  destruction  of  the  renal  substance  is  ef- 
fected, and  the  renal  lesions  apparently  show  that  they  are  pres- 
ent when  the  pathologic  lesions  of  the  renal  substance  are  of  a 


230  UREMIA 

degenerative  or  hyperplastic  character — as,  for  example,  in  renal 
tumors. 

Assuming,  though  admittedly  on  insufficient  evidence,  that 
uremia  is  solely  due  to  some  diseased  condition  or  defective  action 
on  the  part  of  the  kidneys,  the  lesions  present  in  the  other  organs 
must  also  be  considered. 

The  principal  symptoms  of  uremia  are  those  affecting  the 
nervous  system,  chiefly  those  consequent  upon  disorders  of  the 
cerebrum.  The  most  marked  and  constant  lesions  seen  in  the 
brain  consist  in  the  formation  of  a  considerable  serous  exudate, 
particularly  in  the  subarachnoid  space,  and  especially  over  the 
vertex,  although  the  exudation  may  be  general  over  the  entire 
surface  of  the  brain.  Occasionally  the  exudate  is  localized  to 
some  particular  area  of  the  membranes,  thus  accounting,  perhaps, 
for  the  localizing  symptoms,  almost  Jacksonian  in  type,  presented 
by  certain  cases.  This  exudate  is  often  sufficient  to  cause  an 
appreciable  compression  of  the  cortex.  The  vessels  of  the  pia 
are  at  times  congested  in  one  area  and  perhaps  very  anemic 
and  contracted  in  another. 

The  lesions  of  the  brain  tissue  resemble  those  of  the  membranes 
very  closely  in  their  general  nature.  Thus  edema  is  usually 
present  in  greater  or  less  degree;  often  it  is  very  extreme,  and 
large  quantities  of  serum,  usually  very  clear  and  limpid,  drip 
from  the  cut  surface.  The  edema  may  be  localized  and  this  is 
more  common  in  the  cortical  than  in  the  lower  areas,  thus  bearing 
out  the  clinical  manifestations  that  the  more  pronounced  cerebral 
symptoms  are  those  of  cortical  derangement.  The  blood-vessels 
are  often  markedly  congested,  but  they  may  vary  greatly  in  this 
particular,  even  in  the  same  brain.  Microscopically  maceration 
of  the  tissue  immediately  beneath  the  edematous  membrane  is 
generally  observed,  and  this  is  also  sometimes  well  shown  about 
the  perivascular  lymph-spaces  of  the  cerebral  tissue.  Arterio- 
sclerosis is  frequently  seen,  perhaps,  because  when  present  also 
in  the  kidney  it  predisposes  to  the  development  of  uremia. 

If  the  case  has  been  of  long  standing,  or  if  the  subject  has  had 
previous  attacks,  thickening  and  hyperplasia  of  the  connective 
tissue  of  the  pia,  marking  the  site  of  old  exudations,  are  found. 
This  is  the  cause,  at  least  in  some  cases,  of  the  areas  of  opalescence 


UREMIA  23 1 

which  are  found  so  often  along  the  track  of  the  chief  meningeal 
vessels  in  old  nephritic  cases.  In  the  brain  tissue  proper  this 
process  is  represented  by  areas  of  gliomatosis,  generally  of  very 
slight  extent.  From  a  consideration  of  these  lesions  it  can  readily 
be  understood  why  uremia  is  so  commonly  mistaken  for  cerebral 
hemorrhage,  brain  softening,  embolism,  and  other  similar  grave 
and  permanent  lesions.  Changes  have  also  been  found  in  the 
ganghon-cells ;  these  may  amount,  in  severe  or  prolonged  cases, 
to  actual  cell-destruction,  but,  as  a  rule,  they  do  not  extend  beyond 
degeneration,  more  or  less  pronounced,  of  the  chromophyllic 
plaques  of  the  ganglion-cells. 

The  alterations  that  occur  in  the  other  viscera  are  neither  con- 
stant nor  characteristic.  As  a  rule,  hypertrophy  of  the  heart, 
particularly  of  the  left  ventricle,  is  present;  the  blood-vessels  are 
thickened,  at  times  dilated  and  at  others  much  contracted. 

The  edema,  which  is  quite  generally  present  in  the  disease,  is 
usually  due  to  the  primar}^  renal  disease,  although  acute  idio- 
pathic edema  often  develops  in  uremia  and  acts  as  the  immediate 
cause  of  death.  It  is  highly  probable,  however,  that  in  this 
condition  lesions  of  the  central  nervous  system  are  largely 
responsible. 

As  a  general  rule,  the  cause  of  death  in  uremia  is  due  to  cardiac 
failure  or  acute  pulmonary  edema.  In  the  former  the  lesion  of 
the  heart  muscle  may  be  looked  upon  as  due,  at  least  in  part,  to 
the  action  of  the  toxins;  or,  on  the  other  hand,  a  myocarditis 
may  arise  following  primary  renal  disease. 

In  summarizing,  uremia  may  be  defined  as — a  series  of  mani- 
festations, chiefly  nervous,  developing  in  the  course  of  Bright's 
disease,  and  probably  due  to  the  retention  or  presence,  in  the 
blood,  of  certain  poisonous  materials  that  most  likely  result  from 
the  abnormal  action  of  degenerated  renal  cells.  This  is  in  sub- 
stance the  definition  proposed  by  Osier. 

Diagnosis. — In  well-developed,  typical  cases  of  uremia,  when  a 
complete  history  of  the  case  in  question  is  available,  the  diagnosis 
is  easy.  In  its  milder  manifestations,  when  the  symptoms  are 
but  slightly  developed,  the  diagnosis  is  difiicult  and  often  impos- 
sible. A  history  of  headache,  edema,  and  particularly  of  a  dimi- 
nution, especially  very  recent,  in  the  amount  of  urine  excreted, 


232  UREMIA 

is  of  the  greatest  importance.  When  the  urine  is  continuously  of 
low  total  specific  gravity,  and  when  this  cannot  be  increased,  either 
by  quantities  of  water  or  by  reduction  in  the  fluid  intake,  another 
highly  diagnostic  fact  is  added  to  the  clinical  picture.  As  a  rule 
the  sodium  chlorid  output  is  very  small,  irrespective  to  the  intake 
of  this  salt.  When  the  disease  is  fully  developed,  such  symptoms 
as  vomiting,  stertorous  breathing,  coma  or  somnolence,  less  fre- 
quently maniacal  symptoms,  associated  with  increased  blood-press- 
ure, hypertrophy  of  the  heart,  particularly  of  the  left  ventricle, 
and,  perhaps  most  important  of  all,  diminution  in  the  amount  of 
urine  excreted,  together  with  the  appearance  in  it  of  albumin,  casts, 
renal  epithelium,  and  probably  blood,  leave  little  doubt  as  to  the 
diagnosis.  Nevertheless,  circumstances  may  arise,  even  in  the 
most  typical  case,  that  will  greatly  complicate  and  confuse  the 
diagnosis. 

Perhaps  one  of  the  most  characteristic  manifestations  of  uremia, 
and  one  which  permits  its  differentiation,  in  the  majority  of  cases, 
from  diseases  manifesting  similar  symptoms,  is  the  variability  of 
its  clinical  aspects.  The  pulse,  which  in  the  ordinary  case  is  hard, 
full,  and  bounding,  may  within  a  few  hours  become  soft  and  feeble, 
to  be  followed  again,  perhaps,  by  a  return  of  the  high  pressure. 
The  occurrence  and  disappearance  of  edema,  when  present,  is  an 
important  differential  sign. 

There  is  no  one  feature  of  the  disease  that  is  of  greater  value, 
and  at  the  same  time  occasionally  more  misleading,  than  the  con- 
dition of  the  urine.  In  typical  cases  the  amount  of  urine,  and  the 
percentage  of  urea  in  particular,  is  considerably  diminished;  on 
the  other  hand,  some  cases,  especially  those  occurring  in  chronic 
nephritis,  are  particularly  Hkely  to  be  associated  with  polyuria. 
Still  more  rarely  the  urine  may  be  normal  in  amount,  in  chemic 
content,  and  casts  and  epithelium  may  be  entirely  absent.  Re- 
peated examinations  will  usually,  however,  eventually  corrobo- 
rate the  existence  of  nephritis.  The  differentiation  is  partic- 
ularly difficult  when  albuminuria  or  a  true  nephritis  occurs  at 
the  onset  of  an  acute  infectious  disease,  the  picture  of  which  may 
closely  simulate  uremia.  As  a  rule,  the  blood  shows  a  greater  or 
less  increase  in  hemoglobin,  and  chemical  study  shows  a  marked 
nitrogen  retention.  Nitrogen  partition  studies  show  generally 
that  creatinin  is  especially  increased.     Blood  urea  is  mostly  found 


UREMIA  233 

increased  greatly,  and  so  also  may  the  chlorids  of  the  blood,  but,  as 
a  rule,  the  chlorids  seem  to  be  more  retained  in  the  tissues  rather 
than  in  the  body  fluids.  In  many  instances,  of  course,  the  blood- 
pressure  is  increased,  but  in  late  stages  it  may  be  normal  or  even 
subnormal.  As  a  rule,  even  where  in  terminal  stages  the  systolic 
pressure  is  low,  diastolic  pressure  is  likely  to  remain  high,  with  a 
resulting  very  low  pulse  pressure,  which  we  believe  to  be  a  very 
grave  prognostic  sign.  As  a  rule,  the  temperature-cur\'e  in 
any  of  the  acute  infections  is  more  or  less  characteristic,  and  the 
presence  of  a  leukoc3i:osis  aids  materially  in  the  differential  diag- 
nosis. In  typhoid,  hypoleukocytosis,  mononuclear  increase,  and 
the  presence  of  the  Widal  reaction  make  differentiation  certain. 
Miliary  tuberculosis,  particularly  where  early  involvement  of  the 
cerebral  meninges  takes  place,  is  often  distinguished  with  much 
difficulty,  and  frequently  a  differentiation  is  impossible  until 
definite  tubercular  lesions  can  be  demonstrated,  as  in  the  retina, 
or  until  pleurisy  or  peritonitis  develops.  The  differentiation 
from  septicemia  associated  with  albuminuria  may  be  possible 
only  when  metastatic  suppuration  can  be  demonstrated. 

Uremia  is  differentiated  with  particular  difficulty  from  true 
focal  lesions  of  the  brain,  as  in  embolism,  hemorrhage,  or  men- 
ingitis. The  character  of  the  pulse  is  identical  in  many  conditions, 
and  when,  as  is  so  often  the  case,  nephritis  preexisted,  differen- 
tiation may  be  impossible.  This  is  particularly  true  in  cerebral 
hemorrhage.  In  nearly  all  these  conditions  a  positive  diagnosis 
can  be  reached  only  when,  as  almost  always  happens  in  uremia, 
the  picture  of  the  paralysis  suddenly  changes.  There  is  almost 
invariably  a  certain  incoherence  of  symptoms  when  the  case  is 
under  careful  observation,  but  when  seen  for  the  first  time,  an 
absolute  diagnosis  is  impossible.  In  this  relation  it  is  well  to 
remember  that  cerebral  embolism  and  cerebral  hemorrhage  some- 
times occur  in  uremia,  a  fact  amply  demonstrated  in  a  series  of 
postmortems  performed  by  the  writers.  The  ophthalmic  exami- 
nation is  often  of  great  differential  value,  since  the  presence  of 
albuminuric  retinitis,  in  the  absence  of  definite  urinary  manifes- 
tations, may  decide  the  point  in  question. 

The  condition  is  very  commonly  confused,  particularly  in  hos- 
pital and  city  practice,  with  various  forms  of  poisoning.  This  is 
perhaps  most  true  of  alcoholism.     Here  the  history  of  the  case  is 


234  UREMIA 

of  the  greatest  importance.  The  examination  of  the  urine  and 
the  presence  or  absence  of  alcohoHc  tremor  may  also  often  make 
differentiation  possible.  As  a  rule,  besides,  the  delirium  of 
alcoholism  is  of  a  more  active  type  than  is  that  of  uremia.  In 
this  regard,  however,  it  must  be  remembered  that  uremia  occurs 
as  a  common  terminal  condition  in  alcoholism,  as  has  been  dem- 
onstrated to  the  writers  by  a  close  study  of  the  material  derived 
from  the  alcoholic  wards  of  Bellevue  Hospital.  Opium-poisoning 
is  distinguished  with  even  greater  difficulty  than  alcoholism,  when 
the  urine  does  not  present  characteristic  findings.  Ptomain- 
poisoning  and  other  similar  conditions  are  often  confused  with 
uremia,  and  their  distinction  may  demand  a  most  careful  study 
of  the  entire  course  of  the  disease  before  a  positive  diagnosis  can 
be  arrived  at. 

Prognosis. — The  prognosis  in  uremia  is  dependent  on  the  degree 
of  disease  that  exists,  on  the  length  of  time  it  has  been  present, 
on  the  promptness  with  which  treatment  is  begun,  and  on  the 
reaction  of  the  patient  to  this  treatment.  It  also  depends  largely 
on  the  condition  of  the  general  organs  of  the  body,  and  on  the 
readiness  with  which  the  underlying  condition  responds  to  treat- 
ment. In  general,  the  writers  believe  that  the  prognosis  is  more 
favorable  than  is  commonly  supposed.  The  mild  manifestations, 
such  as  headache,  decrease  in  the  amount  of  urine  voided,  symp- 
toms of  early  cortical  irritation,  edema,  and  the  like  can  usually 
be  relieved;  and  when  subsequent  treatment,  associated  with  a 
careful  control  of  the  diet,  exercise,  and  general  habits  of  life,  is 
possible,  the  prognosis  is  good.  In  those  cases  in  which  the 
response  to  medication  is  not  prompt,  the  prognosis  is  generally 
bad.  In  any  case  recurrence,  particularly  when  extra  strain  is 
imposed  upon  the  kidneys,  may  take  place;  and,  although  a 
uremic  patient  may  be  restored  to  comparative  health,  subsequent 
attacks  are  likely  to  develop  at  almost  any  time,  the  second  or 
third  generally  terminating  fatally. 

Treatment. — The  cardinal  feature  in  the  treatment  of  uremia 
should  be  the  stimulation  of  secondary  excretion.  The  bowels 
should  be  freely  opened,  and  oftentimes  the  most  drastic  agents 
are  necessary  for  this  purpose.  Klaterium,  in  doses  of  one-sixth 
of  a  grain,  is  highly  recommended;    croton  oil,  in  doses  of  from 


UREMIA  235 

one  to  three  minims,  repeated  until  the  stools  become  watery, 
is  also  useful.  The  action  of  the  skin  is  to  be  stimulated  by  the 
use  of  hot  packs  and  the  administration  of  pilocarpin,  preferably 
intramuscularly  or  hypodermatically,  in  doses  of  about  one-eighth 
of  a  grain;  when  edema  lessens  the  absorptive  powers  of  the  skin, 
it  should  be  given  by  the  mouth.  When  the  condition  of  the 
heart  is  unfavorable,  pilocarpin  is  to  be  used  with  care.  When 
the  pulse  is  hard  and  bounding,  one  of  the  most  efficient  measures, 
in  the  writers'  experience,  is  the  removal  of  a  quantity  of  blood 
and  the  substitution  of  saUne  solution.  When  necessary,  strych- 
nin and  di gitalin  should  be  employed  to  support  the  heart  action, 
and  vasodilators  should  be  used  freely  when  the  blood-pressure  is 
high.  Of  the  latter,  nitroglycerin,  in  frequent  and  large  doses, 
is  to  be  recommended  for  its  immediate  action,  but  more  per- 
manent benefit  has  been  secured  from  the  use  of  chloral,  as 
recommended  by  Peabody,  Thompson,  and  others,  the  drug  being 
given  preferably  by  the  rectum  in  doses  of  from  30  to  45  grains. 
Chloral,  in  our  experience,  is  one  of  our  most  reliable  vasodilators. 
Although  we  altogether  disagree  with  Fisher  in  his  acidosis 
theory  of  nephritis  and  of  m-emia,  there  is  no  question  whatever 
but  that  alkalis  often  greatly  benefit  these  cases,  either  given  per  os, 
by  rectum,  or  intravenously.  We  have  seen  cases  almost  miracu- 
lously respond  to  this  treatment.  In  other  instances,  of  course,  it 
is  absolutely  without  effect  or,  perhaps,  even  detrimental.  In  our 
opinion  it  should  never  be  pushed  beyond  the  point  of  rendering  the 
urine  alkaline  or  amphoteric. 

If  convulsions  are  present,  they  are  to  be  relieved  by  chloral 
and  bromids,  given  preferably  by  the  rectum  and  in  large  doses. 
Urethane  has  been  highly  recommended  by  Peabody  for  this 
purpose,  but  the  writers  are  not  sufficiently  famiHar  with  it  to 
attest  its  value.  It  may  be  necessary  in  some  cases  to  employ 
chloroform  for  the  relief  of  convulsions,  but,  except  where  imme- 
diate relief  was  demanded,  chloral  has  proved  much  more  satis- 
factory in  the  writers'  hands.  When  the  condition  of  the  patient 
permits,  water  may  be  given  in  large  quantities,  or  saline  enemata 
or  transfusions  may  be  used  when  the  patient  is  unconscious. 
Whenever  possible,  chemical  examination  of  the  blood  should  be 
made  in  conjunction  with  accurate  urinary  studies,  as  we  may  thus 


236  UREMIA 

receive  a  very  definite  idea  of  the  special  poison  retained  in  the 
blood.  The  diet  advisable  must,  in  large  extent,  depend  very 
largely  on  these  findings.  For  example,  salt  must  be  rigidly  ex- 
cluded in  instances  of  salt  retention,  as  in  edematous  cases. 

As  a  general  thing  the  feeding  of  these  cases  is  of  very  little 
consequence;  that  is,  very  little  food  of  any  kind  is  advisable,  and 
it  is  frequently  necessary  to  also  restrict  the  fluid  intake  to  a  mini- 
mum, but  this  also  must  depend  to  a  great  extent  on  whether  or 
not  fluid  is  abnormally  retained  in  the  cavities  or  tissues.  As  a 
rule,  a  considerable  and  sufficient  number  of  calories  may  be  intro- 
duced by  giving  the  lemonade  mixture  mentioned  under  the 
treatment  of  chronic  nephritis. 

The  after-treatment  is  that  of  chronic  Bright' s  disease,  atten- 
tion being  paid  particularly  to  the  diet  and  to  the  habits  of  life, 
as  detailed  under  the  proper  heading.  It  should  constantly  be 
borne  in  mind  that  in  the  treatment  of  uremia  promptness  is  of 
the  greatest  importance,  and  when  one  measure  fails  to  act,  others 
should  be  employed  in  its  stead. 


CHAPTER  XI 

TUBERCULOSIS  OF  THE  KIDNEY.— THE  KIDNEY  IN 

SYPJilLIS 

TUBERCULOSIS  OF  THE  KIDNEY 

There  is  probably  no  other  diseased  condition  of  the  urinary- 
tract  concerning  which  our  knowledge  is  in  a  more  confused  state, 
particularly  as  regards  prognosis,  than  it  is  in  respect  to  tubercu- 
losis of  the  kidney. 

Pathology. — Renal  tuberculosis  occurs  as  a  not  infrequent 
condition  or  complication  in  cases  of  miliary  or  generalized  tuber- 
culosis. Horst  Oertel,  pathologist  to  the  City  Hospital,  reports 
that,  of  the  seven  cases  showing  renal  tuberculosis  which  came  to 
autopsy  at  the  City  Hospital  in  the  year  1904,  five  complicated 
the  pulmonary  disease.  In  four  of  the  seven  cases  both  organs 
were  involved.  Our  personal  statistics  vary  somewhat  from  these 
in  significance,  since  most  of  our  cases  except  those  of  a  clearly 
terminal  character  have  originated  independent  of  detectable 
pulmonary  lesions,  but  were  associated  with  tubercular  lymph- 
adenitis or  with  a  primary  tuberculosis  of  the  lower  urinary  tract. 
Differing  from  the  ordinary  general  condition,  tuberculosis  of 
the  kidney  as  seen  in  the  primary  disease  of  the  genito-urinary 
tract  is  often  found  to  be  monolateral,  and  clinical  observation 
has  convinced  us  that  it  may,  when  properly  supervised,  remain 
so  for  long  periods,  provided  that  secondary  infection  of  the 
bladder  or  urethra  does  not  take  place.  A  sharp  distinction  must 
therefore  be  made  between  those  cases  in  which  renal  tuberculosis 
arises  as  a  terminal  complication  in  a  practically  hopeless  case  of 
tuberculosis,  and  where  it  originates  in,  and  remains  chiefly  limited 
to,  the  urinary  organs.  Joseph  Walsh  ^  found  renal  tuberculosis 
present  in  43  per  cent,  of  loi  consecutive  cases  of  fatal  pul- 
monary tuberculosis.  In  practically  all  these  cases,  however,  in 
1  Third  Annual  Report,  Phipps  Institute. 
237 


238  TUBERCULOSIS   AND    SYPHILIS   OF   THE    KIDNEY 

SO  far  as  we  can  gather  from  the  report,  the  kidney  lesions  were 
purely  terminal  in  nature.  We  believe  it  a  matter  of  great  impor- 
tance that  surgeons  and  pathologists  in  reporting  cases  of  renal 
tuberculosis  realize  this  point,  and  that  in  their  reports  they  lay 
particular  stress  on  the  extent  or  limitation  of  the  disease.  It  is 
quite  possible  that  accurate  data  so  compiled  may  lead  to  profit- 
able modifications  in  prognosis  and  treatment. 

Infection  takes  place  in  two  distinct  ways,  comparable  to  those 
routes  already  discussed  in  regard  to  septic  nephritis,  which, 
in  many  anatomic  characteristics,  closely  resembles  tubercular 
disease : 

Injection  by  ascending  inoculation  from  tubercular  lesions  of 
the  lower  urinary  tract,  as  from  the  urethra,  prostate,  bladder,  or 
seminal  vesicles,  in  any  of  which  foci  the  disease  may  have  origi- 
nated, or  from  tuberculosis  of  the  epididymis  or  testicle.  The 
anatomic  pictures  differ  markedly  in  the  two  classes  of  cases.  In 
ascending  infection,  tubercular  lesions  can  be  usually  found  in  the 
lower  tract  and  a  distinct  pyelitis  or  tubercular  pyonephrosis  is 
demonstrable  anatomically,  and  usually  clinically  as  well. 

Embolic  or  Descending  Infection.- — In  embolic  infection,  unless, 
as  we  have  indicated,  it  take  place  in  a  wide-spread  general 
infection,  the  foci  are  more  apt  to  be  solitary,  discrete,  localized, 
and  may  give  rise  clinically  only  to  the  symptoms  of  renal  granu- 
loma, varying  in  degree  with  the  extent  and  size  of  the  diseased 
areas.  In  this  type  of  infection  the  tubercles,  if  multiple,  are 
mostly  found  in  the  cortex  of  the  organ,  in  the  distribution  of 
the  terminal  interlobular  arterioles,  or  in  the  columns  of  Bertini, 
while  primary  pelvic  invasion  is  the  characteristic  of  the  ascending 
variety.  In  the  former  class  the  course  of  the  disease  and  the 
lesions  as  well  are  very  like  those  seen  in  embolic  septic  processes, 
and,  as  a  rule,  they  pursue  a  relatively  innocent  course  and,  as  will 
be  pointed  out  later,  are  not  commonly  diagnosed  unless  the 
necrosis  of  the  tissue  becomes  sufficiently  extensive  to  cause 
drainage  into  the  pelvis  or  marked  febrile  symptoms.  We  except, 
of  course,  in  this  discussion  those  cases  of  terminal  infection  which 
should  not  be  considered  as  under  the  head  of  renal  tuberculosis. 

Course. ^ — -As  might  be  concluded  from  the  pathologic  anatomy, 
many  cases,  particularly  those  of  embolic  type,  pass  along  with 


TUBERCULOSIS    OF    THE    KIDNEY  239 

few  disturbances  which  attract  the  attention  either  of  the  patient 
or  physician.  The  symptoms  in  these  mild  cases  are  those  of  minor 
and  indefinite  renal  disturbance,  accompanied  in  some  instances 
by  fever,  which  is  dependent  largely  on  the  size  of  the  foci  or  on 
the  presence  of  mixed  infection.  Small  quantities  of  blood  and 
occasionally  leukocytes  appear  in  the  urine,  which  also  commonly 
contains  albumin.  In  case  drainage  into  the  pelvis  takes  place, 
pus  in  greater  or  less  quantity  will  appear  in  the  urine  and  pus- 
casts  are  also  apt  to  be  found.  When  independent  of  general 
disease  or  other  tubercular  lesions,  this  class  of  cases  gives  little 
trouble  as  long  as  the  general  health  is  kept  in  good  condition,  and 
pathologists  are  perfectly  familiar  with  frequent  healed  tubercu- 
lar lesions  in  one  or  both  kidneys  without  any  evidence  of  renal 
disease  being  suggested  by  the  clinical  history  of  the  case.  This 
statement  has  been  called  in  question,  but  our  autopsy  experience 
has  led  us  to  feel  that  it  is  well  founded. 

When  the  infection  is  of  the  ascending  type  and  a  tubercular 
pyelitis  exists,  the  course  of  the  disease  is  not  to  be  distinguished 
clinically  from  that  of  an  ordinary  pyonephrosis,  except  as  we 
may  be  able  to  demonstrate  general  tubercular  lesions,  foci  of 
infection  in  the  lower  urinary  tract,  or  when  examination  of  the 
urine  discloses  the  true  nature  of  the  infectious  process.  When 
drainage  of  the  pus  is  free,  as  a  rule,  the  temperature  does  not  run 
high,  the  pulse  is  not  accelerated,  and  but  little  indication  of  sep- 
tic poisoning  may  be  shown,  and  long  periods  may  elapse  during 
which  no  pus  or  tubercle  bacilli  appear  in  the  urine.  Many  of 
these  patients  continue  at  their  occupation  without  marked  dis- 
comfort except  when  the  ureters  become  more  or  less  plugged  by 
the  necrosed  tissue  and  pus-retention  occurs.  These  cases  may 
even  continue  on  for  a  very  long  time  with  tubercle  bacilli  con- 
stantly present  in  the  urine  without  causing  reinfection  of  the 
bladder,  provided  always  that  care  be  taken  to  prevent  overdis- 
tention  or  other  secondary  disease  of  this  organ.  The  case-books 
of  some  of  the  older  practitioners  who  have  had  the  opportunity  of 
observing  kidney  tuberculosis  extending  over  a  period  of  years 
are  very  interesting.  The  writers  are  indebted  to  the  late 
Dr.  George  Chismore,  of  San  Francisco,  for  the  records  of  some 
cases  of  this  description.     Several  of  his  patients  have  been  able 


240  TUBERCULOSIS  AND  SYPHILIS  OF    THE   KIDNEY 

to  follow  long  and  active  business  lives  with  relatively  slight 
inconvenience. 

Diagnosis. — As  we  have  already  intimated,  diagnosis  in  cases 
of  embolic  infection  can  be  made  only  with  a  certain  degree  of 
probability  when,  in  instances  of  possible  tubercular  infection, 
renal  disturbances,  hematuria,  albuminuria,  and  renal  distress 
without  the  symptoms  of  nephritis  appear.  Where  drainage 
of  necrotic  material  or  pus  into  the  urine  takes  place,  diagno- 
sis rests  on  the  detection  of  the  tubercle  bacillus  in  the  urine. 
Renal  tumor  and  tenderness  are  points  of  importance  in  some 
cases  where  other  growths  of  the  kidney  may  be  reasonably 
excluded  and  where  no  other  lesions  accounting  for  the  fever 
exist.  In  several  such  instances  the  writers  have  employed  the 
tuberculin  test  with  gratifying  success,  but  it  is  very  unreliable 
in  those  cases  where  septic  conditions  exist,  and  may  confuse  a 
possible  reaction.  We  have  thus  far  found  the  Calmette  con- 
junctival and  the  dermal  vaccination  reactions  unsatisfactory 
for  diagnostic  purposes.  The  leukocyte  count  may  be  of  con- 
siderable differential  value  in  some  cases  where  mixed  infection 
is  not  pronounced.  Thus,  in  the  purely  tubercular  disease  no,  or 
but  a  slight,  increase  in  the  total  leukocytes  is  present  and  the 
differential  count  shows  a  relative  increase  in  mononuclear  ele- 
ments, whereas  in  ordinary  infections  the  polynuclear  leukocytes 
are  relatively  increased. 

The  presence  of  tubercular  lesions  in  other  parts  of  the  body 
is  often  strongly  presumptive  evidence  of  the  nature  of  the  renal 
process,  but  one  must  not  allow  himself  to  be  overpersuaded 
in  this  direction,  for  we  have  frequently  found  that  in  such  in- 
stances the  renal  lesions  were  nevertheless  non-tubercular.  Oc- 
casionally the  x-ray  shows  suspicious  shadows  in  cases  of  renal 
tuberculosis,  which  may  greatly  assist  in  diagnosis. 

Where  drainage  of  pus  or  recurrent  or  continuous  hematuria 
is  present,  together  with  renal  tenderness  and  tumor,  the  final 
test  in  diagnosis  is  the  examination  of  the  urine,  which  is  of 
crucial  importance  in  all  types  of  the  disease.  Hematuria  is 
notably  less  frequent  and  less  profuse  in  the  embolic  than  iii  the 
cases  of  ascending  infection. 

In  ascending  infection  we  usually  are  able  to  secure  a  history  of 


TUBERCULOSIS    OF   THE    KIDNEY  241 

gonorrheal  or  other  types  of  inflammatory  disease  of  the  lower 
urinary  tract,  and  careful  inspection  may  discover  possible 
primary  lesions  in  the  testicle,  epididymis,  urethra,  prostate,  or 
bladder.  In  this  class  of  cases  the  lesions  are  quite  apt  to  be 
monolateral.  In  addition  to  these,  we  have  the  symptoms  and 
signs  of  a  pyonephrosis. 

The  recognition  of  the  tubercle  bacillus  in  the  urine  is  by  no 
means  so  simple  a  matter  as  may  appear  on  the  face  of  it,  for  other 
acid-fast  organisms,  morphologically  similar  to  the  tubercle  bacil- 
lus, are  not  uncommonly  found  in  the  urine,  especially  in  cases  of 
pyonephrosis,  and  in  our  opinion  the  most  careful  microscopic 
examination  in  which  the  identification  of  the  bacillus  depends  en- 
tirely on  its  tinctorial  reactions  is  inconclusive  unless  backed  by  a 
typical  clinical  picture  and  by  a  definite  morphologic  identity. 
In  every  case  of  doubt — and  most  cases,  in  our  experience,  unless 
in  the  late  stages,  are  of  this  nature — absolute  identification  can 
only  be  accomplished  by  inoculation  of  the  questionable  pus  into 
the  peritoneal  cavity  of  a  guinea-pig  or  other  susceptible  animal. 
A  serious  drawback  to  this  procedure  is  that  where  mixed  infec- 
tions exist,  as  is  commonly  the  case,  the  experimental  animal 
will  be  killed  by  the  secondary  infecting  organisms  before  the 
tuberculosis  has  sufficient  time  in  which  to  develop.  It  is  our 
practice  to  inoculate  several  animals  with  graded  doses,  and  in 
case  all  survive  two  weeks,  to  kill  the  first  after  four  weeks,  a 
second  after  five  weeks,  and  so  on  until  full  six  weeks  to  two 
months  has  been  allowed.  The  crucial  test  is  the  finding  of 
tubercular  lesions  in  the  liver,  spleen,  and  peritoneum  of  the 
experimental  animal.  Of  course,  there  are  many  cases  in  which 
this  procedure  is  unnecessary,  but  it  is  the  only  means  to  absolute 
diagnosis  in  many  cases  while  they  are  still  in  a  curable  condition. 

The  use  of  antiformin  has  greatly  facilitated  the  search  for  the 
tubercle  bacillus  in  the  urine,  and  it  has  at  the  same  time  rendered 
this  important  step  more  accurate  in  every  respect. 

The   test  is   made  by   adding   to   the   thoroughly   centrifuged 

sediment  of  the  urine  an  equal  bulk  of  30  per  cent,  antiformin 

solution.     This  is  allowed  to  digest  in  the  incubator  at  blood  heat 

for  from  six  to  twelve  hours,  or  until  the  greater  part  has  gone 

into  solution.     This  digestion  may  be  carried  on  at  room  heat, 
16 


242  TUBERCULOSIS   AND   SYPHILIS    OF    THE    KIDNEY 

but  a  longer  time  is  then  necessary.  The  material  is  then  again 
thoroughly  centrifuged,  and  the  fluid,  having  been  poured  or 
pipetted  off,  the  remaining  sediment  is  washed  and  centrifuged 
with  decinormal  salt  solution  until  free  from  the  antiformin. 

The  scant  remaining  sediment  may  then  be  spread  on  slides, 
fixed,  and  examined  in  the  usual  way,  or  it  may  be  injected  into 
experimental  animals.  The  antiformin  acts  by  digesting  away 
most  of  the  organic  material  except  the  tubercle  bacillus,  which 
if  freed  from  the  chemical,  remains  in  a  viable  state. 

This  test  is  especially  accurate,  since  it  permits  the  examination 
of  a  much  larger  bulk  of  sediment  than  is  otherwise  practical. 
Dr.  Felberbaum,  at  the  Montefiore  Home,  has  used  this  method 
extensively  and  highly  commends  it  to  us. 

Evidence  furnished  by  ureteral  catheterization  is  often  of  great 
value,  but  the  irritation  from  the  insertion  of  the  catheter  may 
cause  the  first  urine  passed  to  be  cloudy  with  leukocytes  and 
blood,  and  may  so  mislead;  furthermore,  any  mechanical  irrita- 
tion in  these  cases  tends  to  inoculate  new  foci.  Cystoscopic 
examination  may  show  tubercular  lesions  in  the  bladder,  the 
nature  of  which  may  be  at  once  apparent. 

Before  making  a  cystoscopic  examination  in  suspected  cases  of 
tuberculosis  of  the  kidney,  it  is  the  custom  of  a  German  investiga- 
tor to  observe  the  case  for  several  weeks';  to  wash  the  bladder 
with  a  silver  nitrate  solution,  i  :  10,000,  three  times;  to  examine 
the  urine  microscopically  four  or  five  times  for  the  tubercle  bacillus ; 
and  also  to  inject  into  two  guinea-pigs  the  centrifugated  sediment 
of  the  twenty-four  hours'  urine. 

A  conclusive  diagnosis  of  tuberculosis  of  the  kidney  should 
never  be  made  hastily. 

Prognosis. — It  would  seem  as  though  an  earnest  student  with  a 
fairly  large  clinical  experience  should  be  able  to  give  a  more  defi- 
nite prognosis  in  cases  of  renal  tuberculosis  than  that  expressed 
in  the  words  of  a  well-known  physician,  "You  can  never  tell"; 
but  the  more  we  see  of  the  condition,  the  more  conservative  do 
we  become  in  prognosis.  Much  depends  on  not  only  the  wilHng- 
ness  of  the  patient  to  submit  to  proper  methods  of  treatment, 
regulation  of  the  habits  of  Hfe,  but  also  on  his  abihty  to  do  so. 
The  condition  of  allied  viscera  must  be  considered;  where  serious 


TUBERCULOSIS    OF   THE;    KIDNEY  243 

general  infection  is  present,  the  prognosis  is  obviously  unfavora- 
ble, while  where  the  general  health  is  good  and  the  lesion  not 
advancing  rapidly,  it  is  more  favorable,  or  perhaps  entirely  good. 
Every  physician  can  call  to  mind  cases  of  renal  tuberculosis  in 
which  reasonable  care  has  permitted  the  patient  to  live  until  he 
dies  of  some  independent  disease,  and  the  number  of  cases  which 
appear  on  the  autopsy  table  in  which  completely  healed  tuber- 
culosis of  the  kidney  is  seen  attests  amply  to  the  fact  that,  at 
least  in  some  cases,  our  prognosis  should  be  favorable  rather  than 
otherwise.  We  wish  to  particularly  call  attention  to  this  fact, 
since  of  late  certain  French  surgeons  have  stated  that  healed 
tuberculosis  of  the  kidney  is  never  seen  at  autopsy. 

Treatment. — We  have  in  the  past  neglected  too  much  the  les- 
sons which  have  been  taught  us  in  regard  to  the  management  of 
general  tuberculosis  when  we  come  to  apply  them  to  cases  of  the 
renal  disease.  Outdoor  life,  bracing  but  equable  climates,  and 
good  hygienic  conditions  are  just  as  efficient  in  the  treatment  of 
renal  as  pulmonary  tuberculosis,  and  there  are  no  conditions 
advocated  for  the  pulmonary  disease  in  the  hygienic  or  dietetic 
direction  which  may  not  with  equal  propriety  be  utilized  in  renal 
tuberculosis.  Baths,  well-regulated  exercise,  attention  to  the 
digestive  functions,  and  even  mental  happiness  are  important 
factors  in  the  management  of  these  cases.  We  do  not,  however, 
strongly  indorse  the  absolute  rest  treatment  now  so  popular  in 
the  sanatorium  management  of  general  tuberculosis.  Two  cases 
of  renal  tuberculosis  now  under  the  care  of  one  of  us  have  appar- 
ently made  complete  cures  under  general  hygienic  measures 
only,  and  in  both  instances  without  long  confinement  to  bed  and 
the  house.  Both  returned  to  their  occupation  as  actresses  inside 
of  one  year  after  the  beginning  of  treatment. 

But  little  is  to  be  expected  from  medicinal  treatment.  Some 
urinary  diluents  or  antiseptics  may  at  times  improve  the  condi- 
tion of  affairs,  but  such  drugs  as  creasote,  iodoform,  and  the  Uke 
are  to  be  avoided  as  doing  more  harm  than  possible  good.  We 
have  personally  met  with  no  good  results  with  tuberculin  treat- 
ment, and  we  have  finally  come  to  rely  on  general  medical  and  sur- 
gical methods,  preferably  of  a  conservative  nature,  associated  with 
the  best  of  hygienic  surroundings,  carefully  supervised  but 
generous  diet,  and  a  well-ordered  and  temperate  life. 


244  TUBERCULOSIS    AND   SYPHILIS    OF   THE    KIDNEY 

The  writers  do  not  advocate  operative  measures,  especially 
when  both  organs  are  involved,  except  when  distinctly  surgical 
conditions,  such  as  pyonephrosis,  not  amenable  to  medical  or 
local  treatment,  are  present.  On  the  other  hand,  a  tubercular 
pus  cavity  in  the  kidney  is  subject  to  the  same  surgical  laws  that 
govern  the  treatment  of  a  like  lesion  in  any  other  organ,  and  where 
symptoms  of  sepsis  are  developing  or  where  drainage  has  ceased 
to  be  satisfactory  the  surgeon  must  operate.  The  type  of  the 
operation  must,  of  course,  depend  on  the  conditions  which  he  finds 
on  the  exposure  of  the  diseased  organ.  In  most  tuberculous 
abscesses  that  are  so  extensive  as  to  demand  operative  interference 
the  kidney  should  be  removed,  provided  that  the  associated 
organ  is  not  also  seriously  involved.  Partial  nephrectomy  in 
carefully  selected  cases  may,  perhaps,  fully  comply  with  the 
necessities  of  the  conditions. 

THE  KIDNEY   IN   SYPHILIS 

In  an  article  on  "  Syphilis  of  the  Kidney,"  '  one  of  the  writers 
considered,  somewhat  exhaustively,  the  changes,  properly  attrib- 
utable to  syphilis,  that  are  to  be  expected  in  the  kidney.  No 
evidence  has  been  offered  since  that  time  to  warrant  a  change  in 
the  views  then  expressed.  Early  syphilis  is  associated  with  renal 
hyperemia,  just  as  occurs  in  the  acute  stage  of  other  infectious 
diseases.  In  those  cases  in  which  lesions  already  exist,  perhaps 
as  the  result  of  improper  living  or  previous  disease,  the  hypere- 
mia may  go  on  to  the  formation  of  true  inflammatory  or  degen- 
erative nephritis,  which  may  even  terminate  in  death,  as  in  the 
case  reported  by  Fordyce.^ 

Syphilis  may  cause  an  increase  of  connective  tissue  in  the 
kidney,  and  interstitial  nephritis  is  found  associated  with  such 
frequency  as  to  warrant  the  belief  that  it  is  the  cause,  at  least  in  a 
certain  proportion  of  cases.  It  probably  acts  primarily  by  setting 
up  changes  in  and  about  the  blood-vessels. 

Amyloid  degeneration  of  the  kidney  is   regularly  caused  by 

^  Robert  Holmes  Greene  in  "  Journal  of  Cutaneous  and  Genito-urinary 
Diseases,"  1898. 

*  John  A.  Fordyce,  "  On  the  Occurrence  of  Nephritis  in  Early  Syphilis, 
with  the  Report  of  a  Case  Terminating  Fatally,"  "Journal  of  Cutaneous 
and  Genito-urinary  Diseases,"  1897. 


THE    KIDNEY    IN   SYPHILIS  245 

chronic  syphilis.  Both  amyloid  degeneration  and  interstitial 
hyperplasia,  when  due  to  syphilis,  occasionally  manifest  a  ten- 
dency to  attack  one  kidney  chiefly,  or  solely. 

Gumma  of  the  kidney,  while  rare,  is  now  reported  more  fre- 
quently than  formerly.  They  are  usually  confused  with  renal 
neoplasms,  or  less  commonly  with  stone.  Hematuria  is  a  frequent 
symptom,  as  previously^ referred  to.  J.  Israel*  has  reported  two 
cases  on  which  he  performed  nephrectomy  in  the  belief  that  the 
palpable  tumor  which  proved  to  be  syphilitic  was  malignant; 
several  similar  instances  have  fallen  under  our  personal  observa- 
tion. 

Clinical  experience  in  the  treatment  of  syphilitic  patients  has 
led  the  writers  to  conclude  that  the  condition  of  the  kidneys 
should  receive  more  routine  attention  in  the  treatment  of  this 
disease.  It  should  be  remembered  that  while  mercury  is  of  the 
greatest  value  in  the  treatment  of  syphilitic  affections,  the  drug 
is,  to  a  considerable  extent,  eliminated  through  the  kidneys, 
where  it  may  cause  irritation,  particularly  if  there  is  any  preceding 
kidney  lesion.  On  the  other  hand,  true  syphilitic  changes  in  the 
kidney  may  be  markedly  benefited.  There  is  no  doubt  that  a  true 
syphilitic  inflammation  or  degenerative  process  may  occur  in  the 
kidney,  especially  during  the  aggressive  stages  of  syphilis.  These 
are  oftentimes  entirely  cleared  by  specific  treatment,  either  with 
mercury  or  salvarsan,  but  these  cases  must  be  first  carefully  selected 
and  studied,  for  we  have  seen  cases  of  nephritis  in  undoubted  syph- 
ilitics  apparently  killed  from  an  acute  exacerbation  of  the  nephritis 
induced  by  the  mercury  or  salvarsan.  In  a  case  seen  in  the  writers' 
hospital  service  a  kidney  tumor  half  the  size  of  the  patient's 
head  responded  promptly  to  mercurial  treatment.  The  growth 
had  been  variously  diagnosed  as  tumor  of  the  spleen  and  kidney. 
Catheterization  of  the  ureters  demonstrated  the  presence  of  pus 
in  the  urine  of  the  diseased  side,  and  the  patient  gave  a  history 
of  syphiUs  ten  years  back  and  of  tumor  of  the  left  testicle.  Mer- 
curial injections  were  followed  by  complete  disappearance  of  the 
tumor  in  six  weeks  and  return  to  perfect  health. 

Stimulation  of  the  skin  by  means  of  baths  and  such  daily  exer- 
cises as  will  induce  free  perspiration,  and  so  aid  in  relieving  the  dis- 

1  "  Deutsch.  med.  Woch.,"  Jan.  7,  1892. 


246  TUBERCULOSIS   AND   SYPHILIS    OF    THE    KIDNEY 

eased  kidneys,  is  of  benefit  in  these  cases ;  otherwise  the  treatment 
is  that  of  uncomplicated  syphiHs.  Generally  speaking,  no  opera- 
tive procedure  should  be  adopted  for  the  relief  of  suspected  tumor 
or  stone,  whether  or  not  accompanied  by  hemorrhage  from  the 
kidney,  until  antisyphilitic  treatment — i.  e.,  the  administration 
of  mercury  or  iodin — ^has  been  tried,  though  perhaps  now  that  the 
Wassermann  reaction  has  become  so  accurate,  it  is  unnecessary 
to  waste  this  valuable  surgical  time  except  in  Wassermann  posi- 
tive cases.  Although  the  symptoms  present  may  be  found  but 
rarely  to  be  due  to  syphilis,  still  when  this  is  the  case,  the  imme- 
diate improvement  that  follows  this  treatment  is  most  gratifying. 

Salvarsan  is  reported  by  some  to  have  a  very  dangerous  effect 
on  the  kidney  otherwise  diseased.  The  authors  have  had  the 
opportunity  of  seeing  a  considerable  number  of  cases  treated 
by  this  drug,  and  usually  no  serious  results  of  this  nature  have 
developed. 

The  arsenic  so  introduced  is,  of  course,  eventually  largely 
excreted  through  the  urine,  and  though  resulting  renal  disease 
has  been  recorded,  it  appears  to  occur  only  in  those  cases  abnor- 
mally sensitive  to  arsenic. 


CHAPTER  XII 

MALFORMATIONS  AND  DISPLACEMENTS  OF  THE 
KIDNEY 

CONGENITAL  MALFORMATIONS 

Congenital  malformations  of  the  kidney  are  comparatively- 
common.  They  usually  result  from  flaws  in  the  very  early  devel- 
opment of  the  organ,  and  are  of  relatively  little  importance  to  the 
physician,  though  often  very  confusing  to  the  surgeon,  who  may 
mistake  them  for  new-growths,  or  whose  anatomic  relations  may 
thus  be  grievously  displaced. 

Absence  of  one  kidney  is  not  a  particularly  rare  condition.  As 
a  rule,  in  these  cases  (two  of  which  have  occurred  in  the  writers' 
practice),  the  single  organ  is  practically  equal  in  weight,  size, 
and  in  functional  activity  to  those  of  the  two  organs  of  an  ordi- 
nary subject  of  the  same  body  weight.  This  congenital  anomaly 
is  also  important  chiefly  to  the  surgeon,  who  may,  in  cases  of 
surgical  disease,  remove  the  single  gland  in  the  belief  that  both 
organs  are  present,  with,  of  course,  an  inevitably  fatal  result. 
The  surgeon  should,  therefore,  make  it  a  rule  of  practice  never  to 
perform  nephrectomy  until  he  has  proved,  either  by  palpation 
or  inspection  or  by  the  use  of  the  cystoscope,  that  both  kidneys 
are  present,  together  with  the  relative  degree  of  their  lesions. 

Congenital  lobulation  is  a  very  frequent  anomaly,  but  one  that 
is  of  but  slight  importance.  Ordinarily  it  is  shown  by  a  simple 
marking  of  the  cortex,  but  in  some  cases  it  may  be  as  complete 
as  in  certain  of  the  herbivora.  Occasionally,  the  separation  of  the 
lobules  may  be  marked,  and  the  lobules  be  entirely  isolated. 
This  last  condition  may  lead  to  error  in  diagnosis,  it  being  some- 
times mistaken  for  renal  or  other  new-growths. 

Fusion  of  both  kidneys  into  a  single  mass  is  not  uncommonly 
seen.  The  most  usual  type  of  this  deformity  is  that  in  which  the 
two  organs  are  connected  by  an  isthmus  of  renal  tissue,  the  whole 
forming  a  crescent-shaped  mass  that  has  received  the  name  of 

247 


248 


MALFORMATIONS    AND    DISPLACEMENTS    OF    KIDNEY 


"horseshoe  kidney."  In  this  condition,  as  a  rule,  both  ureters 
are  present  (see  fig.  87),  but  occasionally  there  may  be  but  one 
excretory  duct ;  in  either  case  its  recognition  is  of  but  slight  impor- 
tance. 

Congenital  malpositions  of  one  or  both  kidneys  are  not  uncom- 
monly seen.     As  a  rule,  they  have  but  little  importance  clinically, 

although  in  certain  cases, 
as  was  noted  by  Osier 
they  may  seriously  com- 
plicate diagnosis.  Occa- 
sionally, by  impinging  on 
other  organs,  they  may 
give  rise  to  disease.  This 
is  particularly  true  of  pel- 
vic kidneys  when  preg- 
nancy occurs.  In  a  case 
occurring  in  the  service 
of  the  writers,  both  kid- 
neys were  congenitally 
misplaced  in  the  pelvic 
cavity;  acute  nephritis 
with  fatal  uremia  fol- 
lowed a  twin  pregnancy. 
The  woman  had  passed 
through  a  previous  single 
pregnancy  without 
trouble,  but  in  the  twin 
pregnancy  the  greatly 
enlarged  uterus  so  com- 
pressed one  of  the  mis- 
placed organs  as  to  pro- 
duce actual  strangulation  and  gangrene  with  acute  nephritis  of 
the  other  kidney.  The  condition  was  not  suspected  and  was  dis- 
covered only  at  autopsy. 

One  of  the  most  common  and  important  congenital  anomalies 
is  that  of  cystic  kidney.  Occasionally  but  a  portion  of  one 
kidney  is  so  involved,  but  at  times  both  are  affected.  The  con- 
dition results  from  the  failure  of  the  two  portions   of  the  fetal 


Fig.  87. — Horseshoe  kidney  (one-third  natural 
size).  From  a  specimen  in  the  Museum  of  Carnegie 
Laboratory. 


CONGENITAL    MALFORMATIONS 


249 


arilage  to  unite  properly.  One  of  these  portions,  representing, 
in  the  fetus,  the  anlage  for  the  pelvis  and  medulla,  is  developed 
from  the  Wolfifian  duct;  the  tubules  formed  in  the  intermediate 
cell-mass  of  the  metanephros  should  eventually  fuse  with  those  of 
the  portion  derived  from  the  Wolffian  duct.  Secretion  of  a  more  or 
less  normal  nature  goes  on  in  the  blind  tubules,  with  the  result 
that  they  become  dilated  into  cystic  cavities  filled  with  inspis- 
sated secretion.  The  writers  believe  that  this  is  the  mode  of 
origin  of  many  of  the  isolated  cysts  of  the  kidney  seen  postmortem. 


Fig.  88. — Congenital  cystic  kidney  (one-third  natural  size).  The  accompanying  organ 
was  similarly  diseased  and  both  had  been  removed  surgically  as  supposed  cystic  ovaries. 
Acute  suppression  of  urine  followed,  terminated  by  death  after  three  days.  No  symptoms  indic- 
ative of  renal  disease  had  been  manifested  and  the  urine  was  reported  as  "  normal."  Speci- 
men from  the  Museum  of  Carnegie  Laboratory. 


but  it  is  not  rare  to  find  the  entire  kidney  substance  involved  and 
the  organs  forming  tumors  of  very  large  size,  the  nature  of  which 
may  not  be  suspected  even  on  ocular  examination.  It  is  astonish- 
ing, as  shown  in  the  case  illustrated  in  fig.  88,  to  what  an  extreme 
degree  this  cystic  change  may  exist  and  yet  the  kidneys  remain 
competent  to  fulfil  their  function.  In  the  case  illustrated,  prac- 
tically no  trace  of  normal  renal  tissue  could  be  found,  and  yet  the 
patient  reached  adult  life,  death  occurring  as  the  result  of  anuria 


250  MALFORMATIONS  AND    DISPLACEMENTS    OF    KIDNEY 

following  removal  of  the  cystic  organs  in  the  mistaken  belief  that 
the}^  were  ovarian  tumors.  Before  removing  cystic  tumors  of 
the  abdominal  region  it  is  well,  therefore,  first  to  ascertain  whether 
or  not  they  constitute  the  only  renal  tissue  of  which  the  patient 
is  possessed.  Congenital  cystic  kidney  is  usually  seen  in  mons- 
ters, and  marked  cases  rarely  live  beyond  infancy.  The  condition 
is  not  infrequently  associated  with  sarcomatous  growths. 

Anomalies  in  the  arterial  supply  of  the  kidneys  are  very 
frequent,  but  are  of  interest  chiefly  to  the  anatomist. 

MOVABLE  AND  FLOATING  KIDNEY 
It  is  a  well-known  fact  that  the  kidneys  are  normally  more  or 
less  mobile,  the  movements  being  somewhat  dependent  upon  the 
amount  of  perirenal  fat  present.  This  amount  of  fat  varies,  of 
course,  in  different  individuals,  and  in  the  same  individual  from 
time  to  time.  The  term  "floating  kidney"  is  appHcable  to  those 
cases  in  which  the  movement  of  the  kidney  has  gone  beyond 
the  physiologic  limits;  just  what  these  physiologic  limits  are 
is,  however,  a  very  diflicult  matter  to  determine,  the  personal 
equation  of  the  observer  playing  an  important  part  here.  For 
example,  a  physician  whose  belief  it  is  that  a  great  many  ills  are 
dependent  upon  floating  kidney  would  naturally  be  led  to  regard 
as  a  displacement  or  as  excessively  mobile,  an  organ  that  another 
observer,  of  a  more  conservative  type,  would  consider  entirely 
within  the  normal,  or,  when  displacement  actually  had  occurred, 
would  regard  the  matter  as  of  no  great  importance. 

Pathology. — Some  movable  kidneys  are  said  to  move  inside 
of  the  fatty  capsule,  from  the  absorption  of  fat  between  the  true 
kidney  surface  and  the  fatty  capsule.  Still  another  class  is  believed 
to  be  abnormally  mobile,  owing  to  the  absorption  of  fat  from  both 
inside  and  outside  the  capsule.  In  women,  tight  lacing  has  by 
some  been  held  to  be  one  of  the  reasons  why  the  kidneys  are  more 
often  displaced  in  females  than  in  males.  Unquestionably  the 
relaxation  of  the  abdomen  following  certain  pregnant  states  also 
predisposes  women  to  this  condition,  and  the  lowering  of  intra- 
abdominal pressure  following  rehef  from  large  tumors  or  even 
the  aspiration  of  ascitic  exudates  may  bring  about  the  same 
result.     There  are  also  a  certain  number  of  cases  which  develop 


MOVABLE    AND   FLOATING    KIDNEY 


251 


after  blows  or  injuries  to  the  back  or  sides,  and  still  more  rarely 
one  occasionally  may  see  other  traumatic  cases  following  severe 
falls.  The  condition  is  almost  always  present  in  general  entero- 
ptosis. 

The  term  "displaced  kidney"  is  more  properly  used  to  describe 
those  cases  in  which  the  kidney  remains  quite  permanently  mis- 
placed, while   "floating  kidney"  should  not,  in  our  opinion,  be 


Fig.  89. — Diagram  made  from  jr-ray  photograph,  showing  metal  ureter-catheters  (^A)  in 
position,  and  indicating  how  a  displaced  kidney  may  be  diagnosed.  The  kidney  on  the  right 
side  is  displaced  somewhat. 


applied  unless  the  organ  drops  a  considerable  distance  from  the 
normal. 

Diagnosis. — It  would  be  impossible  to  describe  here  all  the  symp- 
toms of  which  floating  kidney  is  said  to  be  the  origin.  It  has  been 
discovered  that  many  of  these  cases  are  associated  with  neuras- 


252  MALFORMATIONS    AND    DISPLACEMENTS    OF    KIDNEY 

thenia,  and  the  symptoms  of  the  two  conditions  cannot  be  wholly 
separated.  Albarran  asserts  that  floating  kidney  uncomplicated 
by  any  inflammatory  lesions  in  or  connected  with  the  urinary  tract, 
and  when  free  from  pressure,  will  not  cause  systemic  disturbances. 
We  consider  this  statement  as  too  general  to  be  universally  accepted. 
Typical  cases  manifest  a  symptom  complex  known  as  "Dietl's 
crisis,"  which  consists  of  sudden  attacks  of  pain  in  the  back  and  loin, 
accompanied  by  nausea,  vomiting,  and  suppression  of  urine,  fol- 
lowed, after  a  few  hours,  by  the  expulsion  of  a  large  amount  of  urine 
and  immediate  relief  from  pain.  These  painful  attacks  are  believed 
to  be  due  to  pressure  on,  or  to  a  kink  in,  the  ureter,  brought  about 
by  a  displacement  of  the  kidney ;  relief  of  this  obstruction  allows 
the  urine  dammed  back  in  the  pelvis  of  the  organ  to  be  dis- 
charged. 

Malignant  diseases  of  the  kidney,  ureter,  or  surrounding  tissues 
are  hard  to  differentiate  in  some  cases,  as  they  also  give  rise  to 
similar  attacks.  Differential  diagnosis  must  largely  depend  on 
discovery  of  the  malplaced  organ  by  palpation  and  by  rectal  or 
vaginal  examination.  An  x-raj  taken  with  a  metal  ureter  catheter 
in  position,  as  shown  in  our  illustration  (fig.  89),  will  in  cases  of 
doubt  definitely  establish  the  diagnosis.  Our  illustration  is  taken 
from  a  case  of  this  description.  The  writers'  experience  with 
cases  of  displaced  kidney  has  led  them  to  adopt  a  rather  conserva- 
tive view  regarding  the  amount  of  disturbance  ordinarily  pro- 
duced by  lesser  displacements. 

Treatment. — Given  a  patient  who  manifests  Dietl's  crisis,  it 
would  seem  evident  that  some  procedure  should  be  adopted  to 
correct  the  displacement  in  the  hope  of  affording  relief  from  these 
distressing  symptoms.  Many  cases  are  doubtless  cured  by  the 
persistent  use  of  a  properly  fitted  corset  or  support,  or  by  the 
combination  of  this  method  with  such  general  measures  as  tend 
to  deposition  of  normal  adipose  about  the  organ,  thus  tending  to 
retain  it  in  position.  Where  such  measures  fail,  and  they  usually 
do  in  pronounced  cases,  operation  may  be  imperative.  We  do 
not,  however,  advise  operation  merely  upon  the  diagnosis  of  dis- 
placed kidney  when  distinct  symptoms  of  disturbance  are  wanting 
and  where  less  aggressive  measures  suffice.  The  operation  should 
not  be  done  so  much  to  correct  the  displacement  as  to  attempt  to 


HYDRONEPHROSIS  253 

relieve  the  obstruction  to  the  ureter,  which  may,  of  course,  be  also 
due  to  causes  other  than  kidney  displacement. 

In  a  ver}'  large  proportion  of  the  many  operations  performed 
in  this  country  for  the  fixation  of  a  displaced  kidney,  the  symptoms 
complained  of  have  been  those  that  are  generally  considered  as 
indicative  of  neurasthenia,  and  the  operation  has  been  performed 
in  the  belief  that  the  displaced  kidney  was  the  cause  of  the  neu- 
rasthenia. In  a  case  that  came  under  the  observation  of  one  of  the 
writers  several  years  ago  the  patient,  a  young  woman,  was  believed 
to  be  suffering  from  tuberculosis  of  the  kidney.  The  right  kidney 
was  well  down  in  the  pelvic  cavity,  and  was  easily  palpable.  The 
patient  was  thin,  and  it  was  seen  that  the  organ  was  most  mark- 
edly displaced.  The  woman  was  of  a  nervous,  impressionable 
type,  and  her  mind  seemed  to  dwell  on  the  subject  of  tuberculosis 
of  the  kidney  with  such  persistence  that  it  had  become  a  fixed 
idea  in  her  mind.  When  she  was  told  that  no  indications  of  tuber- 
culosis had  been  found,  she  was  skeptical,  and  sought  the  advice 
of  a  well-known  practitioner,  who  subsequently  removed  one  of 
her  kidneys.  Curiously  enough,  however,  he  removed  the  left 
kidney,  allowing  the  right  kidney,  which,  as  previously  stated, 
was  markedly  displaced,  to  carry  on  the  work  of  excretion.  So 
far  as  has  been  learned,  the  result  on  her  mental  condition  has 
been  negative,  but  her  general  health  is  still  good. 

In  most  cases  seen  by  the  writers  in  which  appliances  of  an  ortho- 
pedic type  were  beneficial,  the  patients  were  of  the  neurasthenic 
variety,  and  it  is  doubtful  whether  the  kidney  displacement  was  in 
itself  the  cause  of  the  symptoms  complained  of.  The  writers  believe 
that  displaced  kidneys  may  be  anchored  in  place  with  Uttle  or  no 
danger  to  the  patient.  Permanent  replacement  is  afforded  only  as 
the  result  of  the  operation  of  nephrorrhaphy,  though  general  medi- 
cal treatment,  especially  when  designed  to  increase  the  perirenal  fat, 
as  well  as  to  relieve  annoying  symptoms,  may  give  great  and  even 
permanent  relief. 

HYDRONEPHROSIS 

Hydronephrosis  is  a  condition,  the  general  importance  of  which 
has  been  recognized  by  most  practitioners  in  a  more  or  less  indefi- 
nite way  for  a  long  time,  but  the  discussion  of  the  subject,  except  in 


254  MALFORMATIONS   AND    DISPLACEMENTS    OF    KIDNEY 

its  bearing  on  other  disorders  of  the  urinary  passages,  has  been 
mostly  confined  to  works  on  pathologic  anatomy,  and  the  clinical 
appreciation  of  its  importance  has  been  very  generally  underesti- 
mated, and  is  as  yet  but  very  inadequately  discussed  in  some  works 
dealing  chiefly  with  the  clinical  sides  of  diseases  of  the  urinary 
organs.  Pathologic  anatomists  are  universally  familiar  with  the 
subject,  both  because  of  its  frequency  of  occurrence  at  the 
autopsy  table  and  also  since  it  explains,  in  a  very  considerable 
number  of  cases,  the  appearance  of  definite  signs  and  symptoms 
in  the  development  of  many  diseased  conditions  of  the  kidney  and 
ureter. 

Pathologic  Anatomy.^ — The  pathologic  anatomy  of  hydro- 
nephrosis is  very  simple ;  briefly,  it  consists  of  a  dilatation  of  the 
pelvis  of  the  organ  by  urine.  The  variations  in  the  pathologic 
anatomy  are  chiefly  those  of  degree,  and  to  a  certain  extent  the 
degree  of  the  lesion  is  dependent  on  the  length  of  time  which  the 
condition  has  persisted  and  the  nature  of  secondary  changes 
which  may  have  taken  place,  either  as  secondary  or  concomitant 
lesions. 

In  slight  instances,  the  lesion  may  consist  of  little  beyond 
simple  dilatation  of  the  pelvis  of  the  organ,  usually  with  more  or 
less  erosion  and  desquamation  of  the  pelvic  epithelium.  When 
the  change  is  more  pronounced,  the  calices  of  the  pelvis  are  widely 
dilated  and  excavated  and  replacement  of  the  pyramids  is  shown. 
In  very  pronounced  cases  the  organ  may  be  greatly  increased  in 
size^ — so  much  so  as  to  be  readily  palpable.  In  such  examples 
renal  tissue  is  reduced  to  but  a  narrow  rim  of  cortex  lying  beneath 
a  greatly  thickened  hmiting  capsule  of  connective  tissue  (fig.  90). 
Cases  are  often  seen  in  which  practically  all  renal  parenchyma  is 
so  replaced,  and  one  only  wonders  that  life  can  have  persisted,  for 
occasionally  even  these  pronounced  lesions  are  bilateral. 

Etiology. — The  condition  is  brought  about  in  all  instances  by 
the  mutual  occurrence  of  obstruction  to  the  urinary  outflow  and 
continued  secretion  by  the  organ  on  the  obstructed  side.  Com- 
plete obstruction,  especially  when  of  acute  origin,  is  much  less 
apt  to  produce  the  condition  than  incomplete  or  slowly  develop- 
ing obstruction,  since  where  the  obstruction  is  acute  or  acutely 
complete,  the  increased  intrapelvic  pressure  soon  balances  that  in 


HYDRONEPHROSIS 


255 


the  capillaries  of  the  obstructed  organ,  and  circulation  is  slowed 
and  decreased  and  secretion  finally  completely  checked.  The 
condition  is  much  more  apt  to  appear  where  partial  escape  of 
the  urine  is  possible,  but  as  a  result  of  which  the  intra  pelvic  pres- 
sure is  persistently  increased,  yet  not  so  completely  so  as  to  stop 
secretion.  The  disease  is,  therefore,  seen  most  frequently  in  such 
cases  as  show  a  gradually  and  slowly  increasing  obstruction  to 
urinary  outflow. 

The  condition  may  be  classified  as  congenital  and  acquired. 


Fig.  go. — Hydronephrosis    following    monolateral    stricture    of    the    ureter    (authors' 

specimen). 

Congenital  hydronephrosis  is  seen  as  a  result  of  incomplete  or 
abnormal  development  of  the  urinary  tube,  as  a  result  of  the  pre- 
cipitation within  the  urinary  passages  of  urinary  salts,  or  from 
compression  from  abnormally  placed  viscera  or  vessels.  A  striking 
example  of  the  first-mentioned  condition  was  recently  shown 
us  by  B.  S.  Crowell.  The  specimen  was  from  an  infant  which 
it  was  found  impossible  to  deliver  after  the  head  had  fully 
descended.  Finally,  it  was  found  necessary  to  do  embryotomy, 
and  examination  of  the  dismembered  fetus  showed  enormous 
distention  of  the  abdomen  and  great  general  edema  of   all   the 


256  MALFORMATIONS   AND    DISPLACEMENTS    OF    KIDNEY 

tissues.  The  abdominal  tumor  was  found  to  consist  of  the  two 
tremendously  distended  kidneys,  the  urine  from  which  had  been 
unable  to  pass  into  the  bladder  on  account  of  almost  complete 
congenital  stenosis  of  the  ureters.  This  lesion  was  found  asso- 
ciated with  other  but  irrelevant  congenital  defects. 

Obstetricians  and  pediatrists  frequently  see  cases  where  either 
no  urine  or  one  very  richly  charged  with  precipitates  of  salts  or 
of  free  uric  acid  is  present,  and  in  such  cases  more  or  less  obstruc- 
tion results.  In  a  notable  number  of  instances  this  obstruction 
is  in  the  urethra  in  both  female  and  male  infants,  and  proper 
manipulation  may  at  once  relieve  the  condition.  In  these  cases 
colloidal  substances,  found  so  richly  in  the  urine  of  recently  born 
infants,  of  course,  predispose  to  the  precipitation. 

Acquired  hydronephrosis  may  follow  obstructions  within  the 
urethra,  such,  for  example,  as  stricture  from  the  lodgment  of  stone, 
from  the  formation  of  inflammatory  or  neoplastic  tumors.  Need- 
less to  say,  the  most  frequent  cause  of  urethral  obstruction  is 
stricture,  and  the  relative  percentage  of  cases  of  marked  stricture 
in  which  hydronephrosis  develops  is  large. 

Prostatic  obstructions  are,  perhaps,  the  most  frequent  cause  in 
elderly  men,  and  here  also  the  growth  of  tumors  or  lodgment  of 
stone  must  be  considered  in  the  eliminative  discussion. 

Cystic  lesions  leading  to  hydronephrosis  are  chiefly  of  inflam- 
matory or  neoplastic  origin.  New-growths  in  the  region  of  the 
ureteral  mouths  or  inflammatory  or  tubercular  disease  at  the 
entrance  of  these  ducts  are  among  the  more  frequent  causes, 
while  occasionally  the  lodgment  and  encysting  of  a  calculus  in 
this  region  effects  the  same  result.  Thus  far  the  lesions  concerned 
in  the  production  of  acquired  hydronephrosis  are  relatively  easy 
of  determination  by  any  careful  physician,  especially  for  one 
skilled  in  the  use  of  modern  instruments  of  bladder  search,  but 
the  remaining  causative  factors  can  be  only  problematically  diag- 
nosticated except  by  abdominal  exploration  or  by  the  use  of 
ureter  catheterization. 

Such,  for  example,  are  obstructions  to  the  ureters.  The  most 
frequent  ureteral  lesion  productive  of  hydronephrosis  in  our 
experience  has  been  the  kinking  of  the  tubes  in  cases  of  malplaced 
or  floating  kidneys.     Compression  by  tumors,  either  inflammatory 


HYDRONEPHROSIS  257 

or  otherwise,  and  either  within  or  without  the  ureters,  is  also 
found  relatively  common.  We  have  thus  found  the  condition 
to  originate  in  cases  of  tubercular  peritonitis  or  even  after  bands 
of  adhesions  following  peritonitis  or  operative  adhesions.  It 
was  shown  in  a  recent  case  of  Hodgkin's  disease,  occurring  in  the 
service  of  one  of  us,  where  the  pressure  resulted  from  the  greatly' 
enlarged  lymph-nodes  about  the  ureters.  The  lesion  is  frequent 
in  cases  of  pelvic  tumors  and  inflammations,  especially  in  women 
and  in  cases  of  appendicitis  characterized  by  adhesion  or  marked 
fibrotic  formation.  The  obstruction  to  the  ureters  following 
careless  application  of  abdominal  ligatures  in  peritoneal  surgery 
has  been  generally  noted.  Stone  lodged  in  the  ureters  forms  an 
exception  to  the  general  rule  as  regards  ureteral  obstructions, 
since  in  the  majority  of  cases  the  symptoms  are  sufficiently  char- 
acteristic to  permit  of  absolute  diagnosis.  Strange  as  it  may 
seem,  stone  lodged  in  the  renal  pelvis  rarely  causes  these  conditions. 
Abdominal  tumors,  and  especially  pelvic  growths  of  all  varieties, 
are  very  prone  to  produce  hydronephrosis,  and  from  the  relatively 
greater  frequency  of  these  lesions  in  women  hydronephrosis  has 
been  reported  by  Albarran  to  be  most  common  in  this  sex. 

One  factor,  important  because  it  is  so  commonly  ignored  in  the 
etiolog}^  of  hydronephrosis,  is  the  frequency  with  which  the  con- 
dition occurs  as  a  result  of  the  retention  of  urine  due  to  mental 
or  habit  disturbances.  We  have  often  seen  the  condition  in  those 
moribund  or  ill  with  spinal  or  cerebral  disorders  in  which  the  sen- 
sations of  an  overdistended  bladder  were  not  appreciated.  It 
has  been  found  common  thus  in  hospitals,  where  proper  catheteri- 
zation of  dying  or  comatous  patients  was  neglected,  and  the  fre- 
quency with  which  this  lesion  arises,  especially  in  alcoholism,  dia- 
betes, and  uremia,  should  be  borne  in  mind  by  every  practitioner. 

We  have,  furthermore,  found  hydronephrosis  common,  especially 
in  young  women  working  in  offices  who,  from  feelings  of  delicacy 
or  from  downright  physical  laziness,  do  not  attend  to  their  bladder 
functions  at  regular  or  sufficiently  frequent  intervals.  In  our 
opinion,  with  which  a  prominent  gynecologist  coincides,  this 
factor  is  one  of  the  most  frequent  concerned  in  the  production 
of  ill  health,  and  especially  of  the  backaches  which  are  so  commonly 
complained  of  by  young  women. 
17 


258  MALFORMATIONS    AND    DISPLACEMENTS    OF    KIDNEY 

The  most  serious  results  of  hydronephrosis  are  dependent  upon 
nephritis,  either  in  the  involved  organ  or  in  cases  of  monolateral 
disease,  a  compensatory  nephritis  in  the  other  kidney,  and  second- 
ary inflammatory  disease,  especially  pyonephrosis.  Concerning 
the  relationship  to  this  last-mentioned  condition,  sufficient  mention 
has  been  made  under  the  head  of  Suppurative  Diseases  of  the 
Kidney  (page  184). 

The  symptoms  of  hydronephrosis  are  those  of  the  obstruction, 
such,  for  example,  as  the  colic  which  follows  lodgment  of  a  stone 
in  the  ureter  or  urethra,  or  of  the  pressure  from  enlarged  lobe  of 
the  prostate  or  from  a  tight  stricture,  and  those  symptoms  proper 
of  the  dilated  and  isolated  kidney. 

Backache  is  one  of  the  most  constant  of  these  symptoms.  Slight 
febrile  manifestations  may  be  present  even  in  some  non-infected 
cases.  Where  a  palpable  tumor  is  present,  tenderness  is  usually 
present  over  it,  and  at  times  massage,  gently  performed,  may  cause 
the  evacuation  into  the  bladder  of  a  urine,  light  in  specific  gravity, 
accompanied  by  reduction  in  the  size  of  the  renal  tumor. 

Diagnosis  depends  first  on  the  recognition  of  conditions  which 
might  induce  hydronephrosis,  for  example,  a  tight  stricture,  prob- 
able lodgment  of  a  calculus,  or  detection  of  a  floating  kidney.  In 
this  step  instrumental  examination  with  the  sound  and  cystoscope 
and  the  employment  of  ureteral  catheterization  may  serve  clearly 
to  establish  the  diagnosis.  It  must  not  be  concluded,  however, 
where  a  ureteral  catheter  cannot  be  passed,  even  by  a  skilful  opera- 
tor, that  obstruction  of  sufficient  degree  necessarily  exists  to 
cause  a  hydronephrosis,  since  the  stricture  may  be  due  but  to 
muscular  spasm.  Obviously,  palpation  of  a  renal  tumor  is  pos- 
sible only  in  pronounced  cases,  and  the  absence  of  definite  renal 
tumor  must  never  be  taken  as  negativing  the  diagnosis  of  hydro- 
nephrosis. When,  however,  massage  of  a  renal  tumor  causes  the 
descent  into  the  bladder  of  a  urinary  fluid  with  corresponding 
reduction  in  the  size  of  the  tumor,  the  diagnosis  seems  to  be  clear 
and  decisive,  except  in  some  cases  of  cystic  kidney,  where  this  sign 
may  also  appear.  Where  the  condition  is  monolateral,  cystoscopy, 
with  the  consequent  demonstration,  with  or  without  catheteri- 
zation, that  fluid  escapes  but  from  a  single  side  may  be  diagnos- 
tically  important.     The   symptoms  of  the  condition,   except  as 


HYDRONEPHROSIS  259 

they  indicate  obstruction  in  some  portion  of  the  urinary  tube, 
are  of  but  Httle  assistance  in  diagnosis,  largely  because  of  their 
indefinite  nature  and  very  inconstant  appearance. 

Treatment. — Treatment  should  be  first  prophylactic.  In  all 
operative  procedures  on  the  urinary  tube  care  should  be  taken 
that  nothing  is  done  which  causes  compression,  even  of  relatively 
slight  degree,  of  the  passage.  The  importance  of  this  step,  espe- 
cially in  pelvic  surgery,  needs  but  mere  mention.  Wherever  any 
obstructions  in  the  passage  are  present  which  are  liable  to  become 
more  marked,  they  should  receive  immediate  treatment.  In 
the  early  stages  even  unskilful  massage  along  the  course  of  the 
ureter  may  dislodge  a  stone ;  cauterization  of  an  ulcer  at  the 
urinary  papilla,  with  subsequent  appropriate  treatment,  may  pre- 
vent the  formation  of  a  cicatrix  Likely  later  to  cause  stricture  and 
hydronephrosis.  We  should  especially  like  to  call  the  attention 
of  the  practitioner  to  the  necessity  of  proper  and  early  dilatation 
of  urethral  strictures,  and  to  the  early  rehef  of  cases  of  prostatic 
hypertrophy  which  is  accompanied  by  a  high  intra-urinary  pres- 
sure. Finally,  we  believe  that  it  is  very  important  to  strongly 
advise  in  all  cases  regular  and  habitual  evacuation  of  the  urine  at 
sufficiently  frequent  intervals,  for  we  are  convinced  that  negligence 
in  this  matter  is  responsible  for  hydronephrosis  in  a  very  consider- 
able number  of  cases. 

Curative  treatment  necessarily  lies  chiefly  along  surgical  lines. 
True,  in  some  cases,  very  simple  measures,  such  as  the  replacement 
of  a  dislodged  kidney,  may  effect  a  cure,  or  massage  and  manipula- 
tion dislodge  a  stone,  but  wherever  actual  physical  obstructions 
exist,  they  should,  in  all  cases,  except  those  manifestly  moribund, 
be  removed  as  early  as  possible.  It  may  thus  become  necessary 
to  open  into  the  pelvis  for  the  removal  of  stone,  to  fix  the  kidney 
where  displacement  cannot  be  relieved  by  less  drastic  measures, 
to  release  the  ureters  from  cicatrizing  adhesions,  to  enucleate 
cystic  tumors,  or  to  dilate  or  cut  strictures. 

Where  such  relief  is  impracticable  or  impossible,  it  may  be  neces- 
sary to  open  the  tumor  and  drain  externally.  In  cases  sufficiently 
marked  to  demand  such  measures,  as  a  rule,  secretion  is  very 
slight  in  the  diseased  kidney  and  the  organ  generally  contracts 
down  with  absolute  cessation  of  secretion,  so  that  the  external 


26o  MALFORMATIONS    AND    DISPLACEMENTS    OF    KIDNEY 

drainage  of  urine  is  not  often  a  permanent  nuisance.  Cases  have 
been  reported  where  it  was  necessary  to  implant  the  ureters  either 
to  another  position  on  the  bladder,  to  unite  them  with  the  gut,  or 
transfix  them  in  the  loin.  The  precise  step  in  each  case  must  be 
decided  by  the  conditions  present,  and  good  surgical  judgment  is  as 
indispensable  here  as  in  most  operative  procedures  on  the  urinary 
organs.  The  precise  method  emplo)^ed  must  generally  be  selected  in 
the  midst  of  the  operation,  and  the  ingenuity  of  the  operator  may  be 
severely  taxed  to  produce  the  best  possible  result.  Two  things  of 
importance  must  be  remembered :  whatever  is  done  should  be 
done  as  early  as  possible,  and  before  closing  the  wound  the  surgeon 
should  be  certain  that  all  other  portions  of  the  tract  are  clear 
from  obstructions,  especially  in  cases  of  stone.  This  can  be 
readily  determined  b}^  the  injection  of  sterile  salt  solution,  pre- 
ferably colored,  which  can  be  readily  recognized  as  it  appears  in 
the  bladder  or  from  the  urethra.  For  a  detailed  description  of 
the  surgical  procedures  strictly  applicable  to  the  relief  of  hydro- 
nephrosis, reference  is  made  to  the  chapter  on  the  Surgery  of 
the  Ureter,  and  for  the  Relief  of  Retained  Renal  Secretions. 


CHAPTER  XIII 
WOUNDS  AND  INJURIES  OF  THE  KIDNEY 

WOUNDS  OF  THE  KIDNEY 

"Wounds  of  the  kidney  are  most  generally  due  either  to  a  knife- 
thrust  or  to  a  bullet;  more  rarely  they  are  the  result  of  a  fall  on 
some  sharp  instrument.  When  a  wound  of  the  kidney  is  very 
large,  a  hernia  of  the  kidney  will  take  place  into  the  wound.  The 
condition  is  readily  diagnosed.  Ordinarily,  the  kidney  is  very 
tolerant  of  wounds,  and  if  the  knife  or  bullet  that  inflicted  the 
injury  was  clean,  healing  is  generally  rapid. 

Wounds  of  the  kidney  are,  as  a  rule,  accompanied  by  more  or 
less  shock ;  it  should  also  be  remembered  that  internal  hemorrhage 
may  take  place  and  be  so  severe  as  to  cause  death  before  opera- 
tive procedures  can  be  resorted  to.  A  chemical  examination  of 
the  blood  coming  from  a  wound  in  the  kidney  region  will  demon- 
strate the  presence  of  urine.  A  tumor  in  the  loin  may  or  may  not 
be  present.  If  there  is  a  free  discharge  of  blood  in  the  urine,  the 
tumor  will  not  occur.  Careful  examination  should  be  made  to 
see  that  no  foreign  bodies  have  been  carried  into  the  wound.  Pain 
similar  to  that  of  renal  colic  is  apt  to  be  associated  with  wounds 
of  the  kidney.  Hematuria  is  associated  with  most  wounds  of 
the  kidney.  As  sequels  may  be  mentioned  peritonitis,  suppuration 
of  the  kidney,  cystitis,  and,  after  healing,  rheumatism,  neuralgia, 
and  contraction  of  the  muscles. 

The  prognosis  as  regards  wounds  of  the  kidney  should  be 
guarded.  In  a  series  of  38  wounds  of  the  kidney  inflicted  by 
sharp  instruments,  42  per  cent.  died.  Gunshot  wounds  of  the 
kidney  are  more  Ukely  to  result  fatally  than  those  made  by  cutting 
instruments.  The  prognosis  is  not  necessarily  as  serious  from 
the  wound  itself  as  it  is  from  the  fact  that  they  are  so  often 
associated  with  injury  of  other  organs,  and  the  impossibility  of 
telling  how  much  infection  is  carried  into  the  kidney  by  the  wound- 

261 


262 


WOUNDS    AND    INJURIES    OF    THE)    KIDNEY 


making  agent.  These  wounds  of  the  kidney  are  apparently 
becoming  more  frequent,  in  this  city  at  least,  stiletto  wounds  being 
the  most  common  type.  The  attached  illustration  (fig.  91)  rep- 
resents the  ordinary  appearance  of  a  stiletto  wound  in  the  kid- 
ney, the  patient  dying  from  wounds  through  some  of  the  larger 
blood-vessels,  in  addition  to  those  of  the  kidney.  It  is  important 
to  note  that  wounds  inflicted  by  modern  high-power  weapons  are 


Fig.  gi. — Stab-wound  of  kidney  (authors'  specimen). 

quite  different  from  those  of  the  old  black-powder  guns.  At 
short  range  the  modern  projectile  causes  either  a  small  clean-cut 
wound,  with  little  hemorrhage,  or  else  a  blasting  effect,  with  exten- 
sive laceration;  at  long  range,  a  wound  small  and  clean  cut  gen- 
erally results;  in  either  case  the  wound  is  generally  aseptic. 

The  treatment  of  kidney  wounds,  when  they  are  at  all  extensive, 
is  surgical.  The  operative  procedures  are  dependent  upon  whether 
the  wound  has  involved  the  peritoneum  or  has  only  injured  the 
kidney  outside  of  it.     In  wounds  inside  the  peritoneum,  laparot- 


INJURIES    OF    THE    KIDNEY  263 

omy  should  be  performed ;  in  those  outside  the  cavity,  an  incision 
should  be  made  in  the  lumbar  region  and  the  kidney  exposed. 
In  either  case  hemorrhage  should  be  checked,  the  kidney  wound 
rendered  aseptic  and  sutured,  and  good  drainage  established. 
It  is  not  always  easy  to  thoroughly  clean  the  retroperitoneal  space 
of  any  extensive  hemorrhage  which  may  have  taken  place.  In 
such  cases  especial  care  should  be  taken  to  see  that  thorough 
drainage  is  established.  Wounds  of  considerable  extent  should 
be  tamponed  instead  of  sutured.  The  same  conservatism  as 
regards  operation  should  be  shown  for  wounds  as  for  general 
injuries  of  the  kidney,  and  nephrectomy  should  be  considered  as 
the  operation  of  last  resort. 

INJURIES   OF  THE  KIDNEY 

The  causes  of  injuries  to  the  kidney  are  various.  They  may  be 
due  to  a  blow  on  the  abdomen  or  to  strains  caused  by  lifting  or  jump- 
ing. Now  that  automobile  accidents  are  becoming  so  frequent, 
injuries  to  the  kidney  may  be  expected  to  increase  in  a  correspond- 
ingjdegree.  Curiously  enough,  a  spontaneous  rupture  of  the  kidney 
may  occur  from  the  bursting  of  a  tumor,  two  cases  having  recently 
been  reported  byTufifierand  Hartmann.^  The  subject  of  subparietal 
injuries  to  the  kidney  has  been  must  carefully  studied  by  Francis 
S.  Watson,  and  a  most  exhaustive  and  valuable  contribution  to 
the  literature  of  the  subject  made  by  him.^ 

S)nnptoms  and  Diagnosis  of  Injury  of  the  Kidneys. — 
Following  a  severe  injury  of  the  kidney,  if  recovery  from  the 
shock  has  taken  place,  pain  in  the  renal  region  is  likely  to  follow. 
This  pain  resembles  that  caused  by  a  stone  in  the  kidney,  and 
in  the  male  radiates  down  the  abdomen  into  the  testicle.  The 
pain  sometimes  disappears  soon  after  the  injury,  to  return  in  the 
form  of  nephritic  colic,  which  vanishes  when  a  clot  is  passed.  In 
addition  to  the  pain,  the  most  constant  symptom  is  hematuria. 
Blood  which  coagulates  in  the  ureter  often  passes  out  in  angle- 
worm formed  bodies.  Such  molds  in  the  urine  are  diagnostic  of 
hemorrhage  high  up  in  the  urinary  tract.     More  or  less  swelling  in 

^  "Revue  de  Chirurgie,"  1905. 

''"Subparietal  Injuries  to  the  Kidney,"  "Boston  Medical  and  Surgical 
Journal,"  1905. 


264  WOUNDS    AND    INJURIES    OF    THE    KIDNEY 

the  neighborhood  of  the  injured  kidney  is  generally  associated 
with  the  pain  and  hemorrhage.  When  the  swelling  is  very  marked 
and  diffuse,  hemorrhage  and  urinary  infiltration  are  probably  tak- 
ing place  outside  the  kidney ;  but  if  the  swelling  is  more  firm  and 
circumscribed  than  that  just  described,  filling  the  kidney  space,  a 
hemorrhage  inside  the  capsule  of  the  kidney  may  be  suspected. 

Ecchymoses  are  likely  to  form  on  the  surface  of  the  body  at  the 
seat  of  the  traumatism.  At  times  these  do  not  appear  until  several 
days  after  the  injury  has  taken  place.  If  they  appear  in  the  lum- 
bar or  inguinal  region,  they  are  believed  to  possess  some  diagnostic 
value.  The  urinary  secretion  is  frequently  disturbed,  the  quantity 
of  urine  excreted  being  probably  diminished.  Ureter  catheteriza- 
tion is  a  valuable  aid  in  determining  the  seat  and  extent  of  the  in- 
jury. Recovery  is  usually  rapid  from  the  injury  when  the  kidney 
surface  has  not  been  torn  through.  Even  when  the  parenchyma 
has  been  torn,  the  kidney  manifests  a  tendency  toward  repair. 
In  the  gravest  cases  death  from  internal  hemorrhage  or  shock 
is  likely  to  be  immediate.  In  mild  injuries  the  pain  disappears 
and  the  trifling  hemorrhage  ceases  in  about  forty-eight  hours. 
In  severer  cases  the  hemorrhage  is  more  extensive,  there  is  a 
marked  diminution  in  the  quantity  of  urine  excreted,  and  a  swell- 
ing is  apt  to  appear  in  the  lumbar  region.  When  the  contusion  is 
extremely  severe,  the  kidney  may  be  so  lacerated  as  to  re- 
semble a  pane  of  glass  through  which  a  stone  has  been  thrown — 
there  are  fissures  running  in  all  directions.  Such  severe  injuries 
are  almost  invariably  fatal.  Injuries  of  the  kidney,  if  not  too 
extensive,  have  a  tendency  to  heal  spontaneously,  but  often 
manifest  unpleasant  after-effects.  It  is  possible  that  an  injury 
to  the  kidney  so  slight  as  almost  to  be  overlooked  may  later  give 
rise  to  the  formation  of  multiple  abscesses,  a  single  abscess,  a  cyst, 
or  a  calculus,  or  it  may  serve  as  the  starting-point  for  a  growth  of 
the  kidney.  There  is  a  tendency  on  the  part  of  the  profession  to 
pay  too  little  attention  to  the  serious  after-results  of  kidney  injury. 

Injuries  of  the  kidney  are  not  infrequently  the  cause,  particularly 
in  women,  of  displaced  kidney.  They  are  often,  through  injury 
to  the  ureter  or  the  kidney  pelvis  itself,  the  cause  of  a  hydro- 
nephrosis. Particularly  serious  are  injuries  to  the  kidney  if  the 
accident  occurs  in  kidnevs  that  are  not  in  normal  state.     Neu- 


INJURIES    OF    THE    KIDNEY  265 

man  ^  states  that  he  has  seen  pyonephrosis,  pyonephritis,  pyo- 
cystic  kidney,  ureteritis,  hydronephrosis,  and  papillary  cystoma 
of  the  kidney  from  injury.  With  the  first  three  conditions  he 
believes  gonorrhea  to  have  been  the  exciting  cause,  and  injury 
to  the  kidney  the  contributing  cause.  Some  very  interesting 
experiments  concerning  the  effect  of  an  injury  to  one  kidney  upon 
the  neighboring  kidney  have  recently  been  made  on  dogs  by 
Castaigne.-  Briefly,  he  found  that  a  renal  contusion  caused  for 
a  time  a  diminution  in  the  total  diuresis  and  sometimes  abolishes 
it  for  twenty-four  hours  or  more.  That  later  on  the  after-effect 
on  the  uninjured  side  from  a  transmitted  lesion  of  the  other  side 
was  to  cause  a  condition  of  sclerosis  in  the  well  kidney,  inter- 
mingled with  hypertrophic  zones.  He  seemed  to  attribute  the 
condition  which  took  place  in  the  well  kidne}-  to  the  effect  of  the 
absorption  of  kidney  toxin  from  the  diseased  organ.  There  is 
considerable  clinical  evidence  which  tends  to  support  the  views 
of  Castaigne,  obtained  by  him  from  his  experiments  on  animals. 
Anuria  through  some  reflex  nervous  influence  following  injury  to 
the  kidney  has  been  noticed.  Also,  particularly  by  the  German 
school  of  observers,  has  a  form  of  nephritis,  called  traumatic 
nephritis,  been  noticed  to  occur  several  months  after  an  injury  to 
the  kidney,  the  injury  apparently  being  the  only  causative  fac- 
tor. This  traumatic  nephritis  is  stated  by  at  least  one  observer 
to  be  a  mixture  of  a  parenchymatous  and  interstitial  nephritis ; 
his  views  are  also  corroborated  by  the  very  valuable  work  of 
Beers,  of  New  York,  referred  to  earlier  in  the  article  on  Tests  of 
the  Permeability  of  the  Kidne}',  his  researches  tending  to  show 
that  there  was  increased  functional  activity  in  the  better  kidney 
following  the  removal  of  a  diseased  one. 

The  prognosis  regarding  injuries  to  the  kidney  should  naturally 
be  guarded.  Xot  only  should  it  be  guarded  as  regards  the  imme- 
diate effect  of  the  injury,  but  for  its  later  after-eft'ects,  and  neces- 
sarily it  is  often  rendered  more  difficult  by  injuries  to  the  neighbor- 
ing organs.  Particularly  should  the  prognosis  be  guarded  if  there 
is  any  previous  history  of  disease  in  the  kidney,  an  injury  naturally 
tending  to  make  any  previous  abnormal  condition  worse. 

^  "  Zeitsch.  f.  Chir.,"  1906,  No.  9. 

^  "Gazette  de  Hopitaux,"  October,  1906. 


266  WOUNDS    AND    INJURIES    OF    THE    KIDXEV 

The  treatment  of  injuries  of  the  kidney  must  be  varied  accord- 
ing to  the  nature  of  the  case.  Not  infrequently  the  shock  follow- 
ing injuries  to  the  kidney  is  so  severe  that  the  patient  dies,  although 
no  other  organ  was  involved ;  one  of  the  writers  saw  a  case  of  this 
kind  at  autopsy;  in  suspected  injury  of  the  kidney  the  ordinary 
treatment  for  the  relief  of  shock  should  be  therefore  instituted. 
A  careful  examination  should  then  be  made.  In  a  suspected 
case  of  injury  to  the  kidney,  if  the  recovery  from  shock  is  rapid 
and  blood  soon  disappears  from  the  urine,  the  kidney  again 
assuming  its  functions,  little  is  required  beyond  rest  in  bed,  the 
application  of  an  ice-bag  to  the  injured  region,  and  the  adminis- 
tration of  a  urinary  antiseptic.  The  patient  should  be  kept  under 
constant  observation,  so  that  operation  mav  be  performed  at  once 
if  untoward  symptoms  develop.  After  the  patient  has  so  far  re- 
covered from  the  injury  as  to  be  able  to  be  up  and  about,  he 
should  not  be  dismissed  from  observation,  but  should  be  exam- 
ined at  intervals  for  some  period  of  time,  so  as  to  detect  any 
tendency  toward  the  formation  of  untoward  after-effects. 

If  the  hemorrhage  continues  and  a  marked  swelling  appears 
in  the  lumbar  region,  an  exploratory  incision  should  be  made  and 
the  field  of  injury  carefully  inspected.  It  is  best,  in  doubtful 
cases,  to  make  an  incision  and  examine  the  kidne}^  Such  further 
steps  may  then  be  taken  as  the  exigencies  of  the  case  would  seem 
to  indicate.  Particularh'  should  the  presence  of  any  tumor  in 
the  loin  be  looked  for  and  obser\^ed;  it  having  appeared,  it  should 
be  watched  carefully  for  a  few  days,  and  if  no  tendenc}-  to 
absorption  and  no  amelioration  of  the  general  symptoms  have 
appeared,  operative  procedures  should  be  instituted.  The  oper- 
ation may  vary  from  tampon  and  suture  to  nephrectomy,  varied 
according  to  the  conditions  found  to  be  present,  or  which  may 
develop.  Nephrectomy  should  always  be  the  operation  of  last  re- 
sort in  uncomplicated  cases,  and  in  some  cases  at  least,  if  required, 
should  follow  a  more  conservative  operation.  The  injuries  of  the 
kidney  offer  a  particularly  good  field  for  conser\'ative  surgery. 
This  is  borne  out  by  the  statistics  of  Watson  in  his  paper, 
previously  referred  to,  and  very  recently  other  cases  have  been 
reported  which  tend  to  confirm  this  view.  For  instance,  Chaput^ 
^  "  Revue  de  Chirurgie,"  1905. 


INJURIES    OF    THE    KIDNEY  267 

sutured  a  ruptured  kidney  which  had  a  fracture  extending  the 
entire  length  of  the  anterior  surface ;  he  put  a  drainage-tube  into 
the  pelvis,  and  blood  passed  through  the  incision  for  three  weeks; 
hemorrhage  then  ceased,  and  perfect  cure  resulted. 

Partial  resection  of  the  kidney  maybe  performed  upon  a  ruptured 
kidney.  A.  L.  Franklin  reports  a  most  remarkable  case.^  A  sixteen- 
year-old  girl  felt  something  give  way  after  a  fall  from  a  wagon. 
Pain,  vomiting,  and  hematuria  followed ;  then  a  state  of  gradual  col- 
lapse. Operation  eighteen  hours  after  the  accident — laparotomv; 
the  left  kidney  was  found  torn  to  pieces,  and  the  right  kidney  had 
three  transverse  tears;  the  left  kidney  and  three-fifths  of  right 
kidney  were  removed.  Six  months  later  the  patient  was  well  and 
excreted  normal  urine.  Another  interesting  case  has  been  recorded 
by  Chaput,  in  which  a  large  portion  of  the  kidney  had  to  be  re- 
moved following  injury,  and  in  a  few  days  the  part  of  the  remain- 
ing organ  was  taken  out  and  found  to  have  h}'pertrophied  to  a 
considerable  extent.  These  two  cases,  narrated  above,  also  tend 
to  demonstrate  that  the  views  advanced  from  experiments  on 
animals  are  corroborated  by  clinical  observations  on  man. 

^  "Rupture  of  Both  Kidneys,"  "American  Journal  of  Surgery,"  1906. 


CHAPTER  XIV 
RENAL  CALCULUS 

Under  certain  conditions  stones  are  formed  within  the  urinary 
passages.  Calculi  develop  for  the  most  part  in  the  kidney,  but 
they  may  be  found  in  any  of  the  urinary  passages  into  which 
they  have  subsequently  entered,  where  they  may  either  be  loose 
or  become  encysted. 

Pathology  — One  of  the  chief  causes  of  the  formation  of  renal 
calculi  is  the  presence  of  insufficient  fluid  in  the  urine  to  hold  the 
various  organic  and  inorganic  constituents  that  are  normal  to  it  in 
solution ;  they  therefore  become  precipitated  when  the  fluids  of  the 
urine  are  reduced  and  become  abnormally  saturated  with  these 
chemic  substances.  This  condition  may  arise  when  the  amount  of 
fluids  furnished  the  body  is  deficient,  or  when,  as  in  excessive  pur- 
gation or  diaphoresis,  the  amount  of  fluid  normally  excreted 
through  the  kidney  is  diminished.  The  familiar  appearance  of 
calcium  oxalate  crystals  under  certain  dietetic  conditions,  or  asso- 
ciated with  excessive  perspiration,  is  a  common  example  of  such  a 
state.  The  same  result  may  follow  when  the  chemic  character  of 
the  urine  is  altered,  causing  interaction  and  the  precipitation  of 
certain  bodies,  either  normally  or  abnormally  present  in  the  urine. 
Thus  excessive  acidity  of  the  urine  may  cause  the  precipitation  of 
uric-acid  crystals  even  though  uric  acid  exist  in  but  normal 
amounts.  In  these  respects  the  vital  temperature  acts  very  much 
as  heat  does  outside  of  the  body,  tending  to  prevent  precipitation 
to  a  certain  degree,  and  to  hold  the  salts  in  solution  better  than 
after  the  urine  has  been  allowed  to  cool. 

Rainey,  Ord,  and  Carter  have  shown,  by  an  elaborate  series  of 
experiments,  that  certain  bodies  in  the  urine,  such  as  various 
gums,  albumins,  and  colloidal  substances,  also  tend  to  cause  pre- 
cipitation of  the  salts  of  the  urine ;  these  do  not,  however,  appear 
in  a  crystalline  form,  but  in  a  condition  that  they  term  submor- 

268 


RENAL   CALCULUS  269 

phous,  and  in  which,  the  precipitated  particles,  partly  for  mechanic 
reasons,  adhere  to  one  another. 

Certain  foreign  chemic  bodies,  taken  in  with  the  food  or 
drink,  also  tend  to  cause  a  deposition  of  the  urinary  salts;  thus 
Prout,  Cadge,  and  others  assert  that  this  takes  place  when  the 
so-called  hard  drinking-waters  are  used,  in  this  way  accounting 
for  the  frequent  occurrence  of  renal  calculi  in  certain  districts,  as 
in  some  of  the  counties  in  England. 

In  some  conditions  associated  with  disordered  metabolism  the 
urine  is  called  upon  to  excrete  either  abnormal  substances  or  nor- 
mal substances  in  abnormal  quantities,  and  in  the  course  of  this 
excretory  process  the  material  may  become  deposited  in  the  renal 
tissues.  This  is  well  illustrated  in  certain  cases  of  osteomalacia, 
when  the  breaking-down  of  the  bony  tissue  causes  the  deposition 
of  lime-salts  in  the  tubules  of  the  kidney. 

Gross  foreign  bodies  within  the  urine,  particularly  those  of  a 
sticky  or  albuminous  nature,  seem  to  act  as  exciting  causes; 
thus  the  ova  of  parasites,  echinococcus  booklets,  broken-down 
tubercles,  or  portions  of  necrotic  tissue  originating  from  neo- 
plasms, pyonephrosis,  or  other  inflammatory  and  hemorrhagic 
diseases  of  the  kidney,  tend  to  the  accumulation  of  urinary  salts 
and  the  formation  of  calculi.  This  complication  is  particularly 
likely  to  arise  in  suppurative  processes  in  the  pelvis  of  the  kidney. 

It  is  believed  by  some  that  malnutrition  predisposes  toward 
the  formation  of  renal  calculi,  since  kidney  stones  are  found  most 
frequently  among  the  poorly  nourished.  This  theory  has  not, 
however,  been  sufficiently  substantiated. 

The  chemic  substances  that  go  to  make  up  these  renal  deposits 
vary  under  different  conditions  and  are  dependent  upon  the 
etiologic  factor.  Undoubtedly,  the  most  comrr.on  constituent  is 
uric  acid,  generally  in  crystalline  form.  Calcium  oxalate,  phos- 
phate, and  carbonate  calculi  are  common,  and  when  alkaline  fer- 
mentation has  taken  place,  ammoniomagnesium  phosphate  calculi 
occur.  Xanthin,  cystin,  and  other  rare  chemic  bodies  are  also 
occasionally  the  chief  constituents  of  renal  calculi.  Sodium  urate 
is  one  of  the  more  frequent  types  of  calculi,  particularly  in  gouty 
subjects.  As  a  rule,  however,  calculi  are  made  up  of  mixed  chemic 
substances. 


270 


RENAL    CALCULUS 


The  gross  appearance  of  the  stone  varies,  naturally,  according 
to  its  chemic  constituents,  and  although  most  calculi  contain  more 
or  less  mixed  substances,  the  predominating  chemic  body  gener- 
ally gives  a  more  or  less  distinct  appearance  to  the  calculus.  The 
size  of  the  calculi  varies:  they  may  appear  in  the  form  of  a  dust- 
like powder,  or  may  attain  a  size  sufficient  to  fill  the  entire  renal 
pelvis  or  perhaps  to  erode  the  tissue  of  the  kidney  and  replace 
it  with  the  mass  of  the  calculus.     The  size  and  shape  of  the  cal- 


Fig.  92. —  Kidney  showing  calculi  lodged  in  tlie  calices  of  the  pelvis  (natural  size).     From 
a  specimen  in  the  Museum  of  Carnegie  Laboratory. 

cuius  depend  largely  on  the  portion  of  the  kidney  in  which  it  is 
lodged,  or  on  its  etiology;  thus  the  dust-like  powder  is  most  com- 
mon in  those  cases  of  purely  chemic  origin. 

Calculi  may  be  found  in  the  renal  tubules  or  in  the  interstitial 
framework  of  either  the  cortex  or  medulla  or  in  the  pelvis. 

Stones  found  in  the  substance  of  the  cortex  or  medulla  are  most 
frequently  of  the  fine  granular  variety  and  occur  most  commonly 
in  the  form  of  sand-like  deposit  in  the  cells  of  the  tubules  of  the 
medulla.     They  are  generally  composed  of  uric  acid  or  of  urates, 


RENAL    CALCULUS  27 1 

and  are  most  prevalent  in  gouty  subjects  or  in  children  from 
two  to  fourteen  years  of  age.  The  condition  is  known  s.$  uric-acid 
infarction.  In  early  infancy  the  urine  will  frequenth'  be  found  to 
be  literally  loaded  with  uric  acid  and  urates.  Postmortem  the  de- 
posit is  found  present  in  the  tubules  of  both  medulla  and  cortex, 
but  more  abundantly  in  the  former,  or  perhaps  entirely  covering 
the  mucosa  of  the  pelvis.  In  these  cases  acute  suppression  of 
urine,  followed  by  death,  occasionally  takes  place.  In  uremia 
and  in  some  other  diseases  the  ureters  may  be  found  occluded 
with  the  material;  as  a  rule,  however,  it  disappears  either  spon- 
taneously or  under  proper  treatment,  of  which  flushing  of  the 
urinary  tract  with  abundant  water  forms  the  most  important 
feature. 

A  condition  morphologically  similar  to  this  sometimes  occurs 
in  senile  subjects  or  in  such  diseases  as  are  accompanied  by  exten- 
sive destruction  of  bone.  Here,  however,  the  deposit  is  made  up 
of  calcium  phosphate  and  carbonate,  which  is  found  deposited 
chiefly  in  streaks  outHning  the  medullary  tubules. 

As  a  rule,  the  calculi  of  larger  size  that  are  found  in  the  renal 
cortex  or  in  the  medulla  have  been  formed  as  the  result  of  the 
agglutination  of  smaller  particles  about  a  nucleus  that  is  not  rarely 
of  quite  a  different  nature  from  that  of  the  succeeding  laminae. 
The  small  nucleus  probably  acts  as  a  foreign  body,  causing  the 
formation,  about  it,  of  an  inflammatory  exudate  composed  of 
blood  or  albuminous  fluid,  resulting  in  the  precipitation  of  a  sub- 
morphous  material  that  agglutinates  and  forms  the  calculus, 
which  occasionally  takes  on  the  greatly  exaggerated  form  of  a 
urinary  tubule  or  glomerulus.  Generally,  the  uric-acid  calculi 
formed  in  this  manner  are  very  hard,  smooth,  and  dark  brown  or 
red  in  color ;  those  made  up  of  calcium  oxalate  are  rough,  covered 
with  sharp  spicules  or  nodules,  and  are  white  in  color,  although 
stained  more  or  less  with  blood-pigments.  The  larger  phosphatic 
calcuH  are  rarely  found  in  this  portion  of  the  kidney,  but  usually 
lodge  in  the  pelvis,  although  oftentimes  their  nuclei,  probably 
formed  in  the  cortex  or  medulla,  consist  of  urates  or  oxalates. 

Pelvic  calculi  may  be  of  large  or  small  size,  or,  as  previously 
stated,  may  take  the  form  of  a  sand-like  deposit.  When  they 
are  retained  in  the  pelvis  for  any  considerable  length  of  time  they 


272 


RENAL   CALCULUS 


tend  to  increase  rapidly  in  size,  this  being  largely  due,  probably, 
to  the  secretion  of  mucus  excited  by  their  presence  in  this  portion 
of  the  urinary  tract.  They  are  extremely  likely  to  set  up  suppu- 
ration, and  when  alkaline  fermentation  is  added  to  the  existing 
elements  that  predispose  toward  calculus  formation,  the  stone  will 
increase  rapidly  in  size,  so  that  the  entire  pelvis  may  be  found  to 
be  occupied  by  a  laminated  calculus  that  forms  a  perfect  mold  of 
the  cavity. 

If  the  calculi  are  small,  they  will  very  possibly  be  passed  through 
the  urinary  tract  without  the  patient's  knowledge,  or  slight  pain, 
hematuria,  and  the  like  may  accompany  their  exit;  at  other 
times  they  may  become  encysted  in  the  renal  tissue.  In  the  male 
they  frequently  pass  into  the  bladder,  being  retained  there;  in 
the  female,  owing  to  the  different  anatomic  conditions,  they  are 
more  commonly  passed;  this  probably  explains  the  greater  fre- 
quency with  which  cvstic  calculi  occur  in  men.  Not  rarely  the 
calculus,  in  its  passage  through  the  ureter,  may  become  lodged 
there,  causing  obstruction  of  that  canal.  If  this  takes  place,  it 
necessarily  interferes,  to  more  or  less  of  a  degree,  with  the  urinary 
outflow.  The  immediate  results  of  this  obstruction,  be^^^ond  the 
disturbance  caused  by  pain,  may  not  be  serious.  The  late  after- 
results,  if  the  obstruction  by  the  calculus  is  confined  to  one 
ureter,  will  be  hydronephrosis  or  renal  atrophy  on  the  affected 
side.  Beyond  a  certain  amount  of  pain,  but  little  disturbance 
may  result.  If,  however,  calculi  become  lodged  in  both  ureters, 
death  will  follow  unless  prompt  operative  measures  be  taken. 

Symptoms. — Renal  calculus  may  be  present  without  giving  rise 
to  any  symptoms.  Stones  of  considerable  size  are  not  infrequently 
found  at  autopsy,  embedded  in  the  kidney  substance  or  inclosed 
in  the  pelvis,  that  gave  no  manifestations  of  their  presence  during 
life.  In  typical  cases  the  patient  complains  of  pains  in  the  renal 
region,  commonly  radiating  downward  toward  the  bladder  or 
groin  and  into  the  testicle;  occasionally  they  are  referred  to  the 
opposite  side.  These  pains,  accompanied  by  a  sensation  of  weight, 
are  exaggerated  on  violent  exercise. 

As  a  rule,  crystals  or  renal  sand  are  found  in  the  urine  with  more 
or  less  regularity ;  leukocytes  and  red  blood-cells  are  also  commonly 
present,  particularly  following  active  exercise.     Pus  may  also  be 


RENAL    CALCULUS  273 

present  when,  as  is  generally  the  case,  infection  has  taken  place. 
When  obstruction  of  the  ureter  occurs  from  time  to  time,  the  urine 
is  excreted  in  small  amounts  until  the  calculus  is  displaced,  when 
there  is  a  sudden  gush  of  urine,  which  is  usually  clouded  with 
leukocj^es,  and  most  probably  with  sand  and  desquamated  pelvic 
or  ureteral  epithelium,  and  with  large  quantities  of  mucus. 

Paroxysmal  pain  occasionally  manifests  itself,  even  when  the 
stone  is  too  large  to  engage  in  the  ureter;  this  pain  is  sometimes 
so  severe  as  closely  to  simulate  the  renal  colic  that  develops 
when  stones  enter  the  ureters  and  pass  downward  toward  the  blad- 
der. Renal  colic  is  particularly  prone  to  develop  after  exercise 
or  from  any  cause  that  tends  to  displace  the  stone.  It  is  ushered 
in  with  extremely  severe,  cramp-like  pains,  generally  in  the  renal 
region  of  the  affected  side,  and  radiating  from  this  point  outward, 
principally  downward  along  the  urinary  tract ;  it  is  often  locaUzed 
at  the  head  of  the  penis  or  in  the  testicles.  Severe  chill,  nausea 
and  vomiting,  and  sometimes  violent  diarrhea  may  appear;  the 
pulse  becomes  weak  and  rapid,  and  the  skin  bathed  in  a  cold 
perspiration.  These  symptoms  abate  only  when  the  stone  has 
passed  into  the  bladder  or  when  the  contractions  of  the  ureter 
have  ceased.  One  occasionally  sees  cases  at  autopsy  in  which  the 
calculus  has  paused  in  its  transit,  obstructing  the  ureter,  and 
becoming  encysted  in  this  region.  When  the  stone  has  been 
passed,  there  is  usually  a  gush  of  blood-stained  urine,  which  is 
turbid  with  cells  from  the  urethral  mucosa  and  with  mucus  and 
leukocytes. 

Although  the  characteristics  of  renal  colic  are  quite  marked, 
the  condition  may  occasionally  be  mistaken  for  gall-stone  colic ; 
the  diagnosis  can  be  verified  only  by  an  examination  of  the  urine 
following  the  attack.  The  calculus  may  be  discovered  by  means 
of  the  cystoscope  or  sound  in  the  bladder,  or  when  the  stone  is 
forced  out  through  the  urethra,  the  patient,  if  a  male,  generally 
becomes  aware  of  the  fact. 

Diagnosis. — As  previously  indicated,  the  diagnosis  of  the  con- 
dition is  based  on  the  pain,  the  examination  of  the  urine,  the 
cystoscopic  findings,  and  the  determination  of  existing  obstruc- 
tion in  the  ureters.  Harrison  believes  it  possible  to  detect  the 
presence  of  a  renal  calculus  by  a  peculiar  grating  sensation  that 
18 


2  74  RENAL   CALCULUS 

is  conveyed  to  the  hand  when  the  kidney  is  palpated.  The  writers 
have  never  been  able  to  verify  this. 

The  x-ray  now  affords  a  means  by  which  the  larger  renal  calculi 
may  easily  be  located.  The  character  of  the  stone,  however,  has 
much  to  do  with  its  clear  definition  by  the  rays,  and  the  result 
depends  largely  upon  the  experience  and  skill  of  the  photographer. 
Some  photographers,  particularly  in  the  larger  cities,  are  becoming 
so  skilful  in  this  line  of  work  that  they  seldom  fail  in  their  efforts 
if  the  stone  is  of  any  considerable  size. 

The  ureter  catheter  or  bougie,  having  its  tip  coated  with  wax, 
is  of  great  diagnostic  aid  in  renal  calculus.  A  stone  in  the  ureter 
or  pelvis  of  the  kidney  will  betray  its  presence  by  the  feel  and  by 
the  scratches  it  makes  upon  the  wax. 

As  mentioned  in  a  previous  chapter,  massage  over  the  region  of 
the  suspected  kidney  and  ureter,  for  the  purpose  of  forcing  their 
contents  into  the  bladder,  followed  by  immediate  examination  of 
the  urine,  may  aid  in  making  a  diagnosis,  particularly  if,  after 
such  massage,  the  urine  is  bloody. 

Treatment. — The  treatment  divides  itself  naturally  into  three 
parts:  (i)  The  prophylactic  treatment;  (2)  treatment  of  stones 
lodged  in  the  renal  tissue  or  pelvis;  (3)  the  treatment  of  renal 
colic. 

When  a  predisposition  to  the  formation  of  calculi  is  known  to 
exist,  or  when  the  urine  is  frequently  clouded  with  uric-acid  crys- 
tals or  with  calcium  oxalate,  the  patient  should  be  directed  to 
drink  large  quantities  of  water ;  for  this  purpose  distilled  water  or 
any  of  the  alkaline  waters  may  be  used  with  benefit,  the  good 
results  being  probably  due  more  to  the  quantity  of  fluid  passed 
than  to  the  character  of  the  water  taken ;  by  the  use  of  the  alka- 
line waters,  however,  as  in  the  special  instances  just  mentioned, 
the  chemic  nature  of  the  urine  may  become  so  altered  as  to  hold 
in  solution  certain  crystalline  bodies  that  might  otherwise  become 
precipitated  into  the  substance  of  the  kidney.  Good  effects  have 
been  reported  from  the  use  of  large  doses  of  glycerin  given  by 
stomach.  Those  acid  fruits  and  vegetables  that  are  known  to 
increase  the  presence  of  calcium  oxalate  crystals  in  the  urine 
should  be  avoided,  and,  in  the  case  of  uric-acid  crystals,  such 


RENAL    CALCULUS  275 

dietetic  rules  should  be  observed  as  will  minimize  the  danger  of 
an  excessive  output.  In  certain  cases  good  results  are  obtained 
from  the  use  of  lithia  or  sodium  or  potassium  bicarbonate  in  full 
doses.  On  the  whole,  however,  the  most  important  feature 
of  the  treatment  is  the  drinking  of  increased  quantities  of  water. 
Once  a  calculus  of  considerable  size  has  formed  in  the  renal  tissue 
or  in  the  pelvis  of  the  kidney,  it  is  very  doubtful  whether  any  of 
these  measures  are  of  benefit,  although  certain  waters  are  said  to 
possess  remarkable  curative  powers  in  this  direction.  When  alka- 
line fermentation,  associated  with  infection,  has  taken  place, 
urinary  disinfectants,  such  as  salol,  urotropin,  and  the  salicylates, 
have  been  used  with  benefit. 

The  first  step  in  the  treatment  of  renal  colic  consists  in  reliev- 
ing the  intolerable  pain.  As  a  rule,  hypodermatic  injections  of 
morphin  will  be  required,  or,  when  these  fail  to  give  sufficient 
relief,  chloroform  inhalations  may  be  demanded.  Hot  sitz-baths, 
hot  poultices  to  the  renal  region,  and  the  drinking  of  hot  water  are  all 
useful  measures.  In  several  instances  the  writers  have  employed 
atropin  hypodermatically  with  excellent  results,  both  as  regards 
relief  from  pain  and  as  a  means  of  preventing  the  muscular  spasm 
which  is  "apparently  largely  responsible  for  the  pain.  At  the  same 
time  this  relief  seems  to  facilitate,  at  least  in  some  cases,  the  pas- 
sage of  the  stone.  When  the  acute  attack  begins  to  subside,  lithia 
citrate  or  sodium  bicarbonate,  with  abundant  quantities  of  water, 
associated  with  a  diet  tending  to  reduce  the  urinary  solids,  and  par- 
ticularly those  elements  that  make  up  the  stone,  is  to  be  recom- 
mended. After  these  attacks,  the  stone  should  always  be  sought  for 
in  the  urine  or,  if  necessary,  in  the  bladder,  for  a  knowledge  of  its 
nature  serves  as  an  excellent  guide  to  the  most  appropriate  sub- 
sequent treatment,  both  dietetic  and  medicinal. 

As  to  the  best  method  of  effecting  removal  of  a  calculus,  each 
case  is,  in  a  way,  a  law  unto  itself.  Fortunately,  nephrotomy  for 
the  removal  of  stone  is  not  usually  a  very  serious  operation ;  much, 
of  course,  depends  upon,  the  condition  of  the  patient  and  upon 
the  size  and  location  of  the  stone  Edebohls'  incision,  which  will 
be  described  further  on,  is  the  one  ordinarily  to  be  recommended. 
After  the  kidney  has  been  exposed,  the  stone  should  be  searched 
for  by  means  of  needles  run  through  the  kidney  in  various  direc- 


276  RENAL   CALCULUS 

tions.  Once  found,  it  is  generally  comparatively  easily  removed 
with  forceps  through  an  incision,  followed  by  packing  the  wound 
if  hemorrhage  is  severe.  If  the  opportunity  presents  itself  during 
the  operation,  the  permeability  of  the  ureter  may  be  ascertained 
at  this  time,  or  this  may  subsequently  be  learned  by  ureteral 
catheterization.  A  further  and  more  complete  consideration  of 
the  surgical  treatment  for  renal  calculi  will  be  found  later  in  the 
chapter  dealing  with  the  surgery  of  the  kidney. 


CHAPTER  XV 

TUMORS  OF  THE  KIDNEY 

Renal  tumors  are  relatively  rare ;  this  is  particularly  true  of 
those  neoplasms  that  affect  the  kidney  primarily,  and  it  is  with 
these  primary  growths  that  we  are  chiefly  concerned,  for  secondary 
renal  growths  are  seldom  of  much  clinical  importance,  and  usually 
occur  but  as  a  local  manifestation  of  a  fatal  generalized  disease; 
but  little  is,  therefore,  gained  by  their  treatment. 

The  new-growths  of  the  kidney  are  best  divided  into  three 
classes — granulomatous,  parasitic,  and  neoplastic.  The  first 
includes  isolated  tubercles,  gumma,  and  actinomycotic  foci.  As 
regards  the  relative  occurrence  of  tumors  of  the  kidney  Kelynack, 
in  an  analvsis  of  306  primary  renal  growths,  found  1 15  sarcomata, 
22  myosarcomata,  145  carcinomata,  15  fibromata  or  lipomata,  and 
12  adenomata.  In  this  series  the  author  failed  to  consider  the 
hypernephroma,  which  probably  formed  a  considerable  propor- 
tion of  the  tumors  listed  as  sarcoma  or  carcinoma. 

Tuberculosis  and  gumma  of  the  kidney  are  more  appropriately 
discussed  elsewhere  under  special  heads.  Actinomycosis  is  very 
rare,  and  has  never,  in  so  far  as  we  have  been  able  to  learn,  been 
found  primarily  in  the  kidney. 

Parasitic  tumors  are  seen,  due  to  the  action  of  the  echinococcus 
and  to  the  Cysticercus  cellulosae.  Hydatid  cysts  of  the  kidney 
are  not  particularly  uncommon  where  hydatid  disease  is  frequent, 
but  it  has  been  but  rarely  reported  in  this  country,  and  we  have 
seen  but  a  single  case.  The  cysts  present  nothing  of  special 
note,  and  may  be  either  large  or  small.  The  condition  is  commonly 
found  associated  with  other  cysts  elsewhere.  The  Cysticercus 
cellulosae  is  exceedingly  rare,  and  in  so  far  as  we  can  learn,  has 
never  been  observed  in  America. 

The  true  neoplasms  of  the  kidney  are  most  conveniently  classed 
as  innocent  and  malignant.  The  benign  tumors  of  the  kidney 
are  of  relatively  little  importance,  and  there  is  surprisingly  little 
general  or  local  disturbance  following  their  development  in  the 

277 


278 


TUMORS    OF    THE    KIDNEY 


renal  tissue.  Named  in  their  relative  order  of  occurrence,  the 
chief  innocent  tumors  of  the  kidney  are  fibroma,  lipoma,  myomata, 
and  angioma.  Fibromata  occur  most  commonly  in  the  cortical 
portions  of  the  organ,  less  frequently  in  the  capsule.  They  are 
usually  round,  and  appear  as  small,  rarely  large  masses  of  connec- 
tive-tissue fibrils  arranged  usually  in  whorl-like  bodies.  In  some 
cases  they  appear  to  have  originated  about  tinv  blood-vessels, 


Fig.  93. — Lipoma  of  kidney  (authors'  case). 


perhaps  as  a  result  of  inflammatory  hyperplasia,  but  in  other 
instances  they  are  unquestionably  truly  neoplastic.  As  a  rule, 
they  are  not  well  differentiated  from  the  stroma  of  the  organ. 
Lipomata  are  growths  from  the  capsule  in  practically  all 
instances.  They  may,  as  illustrated  in  fig.  93,  be  of  considerable 
size,  and   though  well  differentiated  from  the  renal  tissue,  they 


TUMORS    OF    THE    KIDNEY 


279 


may  cause  considerable  pressure  atrophy  or  erosion  of  the  renal 
tissue,  as  was  the  case  with  the  lipoma  illustrated.  Myomata 
are  of  two  classes — leiomyoma  and  rhabdomyoma.  The  former 
growth  is  commonly  found  in  the  capsule  and  is  of  small  size. 
Occasional  isolated  smooth  muscle-cells  may  be  found  in  some 
fibromata.  Rhabdomyomata,  or  striped  muscle  tumors,  are 
most  frequently  found  in  infants,  and  they  are  associated  in  most 
cases  with  sarcomatous  or  teratomatous  neoplasms.  They  are 
often  of  large  size,  and  infiltrate  the  renal  tissue  diffusely,  so  as 
to  make  enucleation  impossible  without  total  nephrectomy. 
Manifestly,  they  are  usually  more  or  less  malignant,  and  in  most 
of  such  cases  they  grow  rapidly  and  set  up  fairly  early  metastases. 
As  growths  which  also  possess  a  semi-malignant  nature  at  times 
are  the  adenoma  and  papilloma.  Adenomata  are  reported  by  the 
older  authors  as  relatively  frequent,  but  as  we  grow  more  familiar 
with  the  hypernephromata,  most  of  us  are  inclined  to  place  among 
these  many  or  most  of  the  tumors  previously  considered  as  ade- 
nomata. Thus  two  cases  of  adenomata  of  the  kidney  reported 
by  one  of  us  have  been  subsequently  classified  as  hypernephro- 
mata. True  adenomata  of  the  kidney  are  probably  rare.  They 
occur  as  well-encapsulated  masses  of  tissue,  made  up  of  tubular- 
like  arrangements  of  epithelial  cells,  which  resemble  but  do  not 
fuse  with  the  tubes  of  the  renal  parenchyma.  Adenomata  are 
chiefly  reported  as  occurring  in  the  cortex.  Papilloma t a  of  the 
kidney  are  seen  almost  exclusively  in  the  pelvis.  They  are  of 
considerable  importance,  since  relatively  frequent  and  because 
calculi  are  apt  to  form  about  them.  They  also  probably  even- 
tually become  malignant  in  a  considerable  percentage  of  cases. 
Angiomata  are  usually  found  in  the  cortex  of  the  kidney  and  are 
commonly  of  small  size.  They  are  most  likely  to  be  found  in 
conjunction  with  hemangiomata  in  other  organs,  notably  in  the 
liver,  heart,  or  skin.  They  are  probably  mostly  congenital  in 
origin,  but  may  follow  inflammation  or  the  necrosis  subsequent 
to  embolic  infarction. 

According  to  Kelynack,  of  all  malignant  tumors,  those  occur- 
ring primarily  in  the  kidney  form  but  3  per  cent,  of  the  total,  but 
Virchow  reports,  however,  that  5  per  cent,  so  occur. 

A  point  of  considerable  interest  is  the  fact  that,  of  malignant 


28o  TUMORS    OF    THE    KIDNEY 

growths  of  the  kidney,  by  far  the  larger  percentage,  even  of  the 
carcinomata,  are  stated  to  occur  in  children,  usually  under  fifteen 
years  of  age.  The  writers'  experience  has  been  chiefly  limited  to 
adults,  which  may  account  for  the  fact  that  renal  new-growths 
have  been  found  so  rarely  by  them.  Thus  in  656  consecutive 
complete  postmortem  examinations,  40  cases  of  malignant  tumor 
were  found,  but  three — one  sarcoma  and  two  hypernephromata — 
of  which  occurred  primarily  in  the  kidney. 

Carcinoma. — Carcinomata  of  the  kidney  are,  as  a  rule,  of  the 
tubular  variety.  They  are  often  of  the  so-called  roseate  form, 
and  to  the  unaided  eye  appear  to  have  a  firm,  dense,  white  center, 
from  which  branches  radiate  like  the  spokes  of  a  wheel.  They 
are  frequently  seen  to  be  distinctly  encapsulated,  although  micro- 
scopically the  tumor-cells  are  commonly  found  to  have  penetrated 
this  enveloping  membrane.  There  can  be  no  question  but  that 
some  cases  reported  as  renal  carcinomata  are  in  reality  hyper- 
nephromata. Two  instances  originally  reported  by  one  of  the 
writers  as  primary  carcinomata  have  been,  in  the  light  of  more 
recent  research,  properly  included  under  the  hypernephromata. 
It  is  doubtless  true,  as  has  often  been  claimed,  that  renal  calculi, 
and  particularly  pelvic  stone,  plav  a  part  in  the  production 
of  carcinoma,  generally  of  the  epitheliomatous  variety.  Pelvic 
epitheliomata,  which  are  relative^  frequent,  originate  from  the 
mucosa  of  the  pelvis,  and  also  arise  from  papillomata;  indeed,  this 
possibility  is,  in  the  writers'  opinion,  one  of  the  principal  reasons 
why  operative  procedure  is  so  strongly  indicated  in  these  cases  of 
pelvic  papillomata. 

Sarcomata  of  the  kidney  are  commonly  seen  in  childhood,  and 
are  generall}^  of  congenital  origin ;  they  may  be  found  well  developed 
at  birth.  As  is  naturally  to  be  expected,  these  congenital  sarco- 
mata assume  many  of  the  characteristics  of  the  teratomata.  Thus 
a  considerable  number  of  them  are  myosarccmata,  often  of  the 
class  of  rhabdomyosarcomata,  and  they  contain  elements  character- 
izing them  as  congenital  neoplasms,  and  indicating  that  they  origi- 
nate as  the  result  of  improper  fetal  development  of  the  intermediate 
cell-mass.  So  far  as  the  writers'  experience  with  this  class  of 
tumors  goes,  epithelial  elements  in  the  tumor  are  wanting;  but 
Larkin  has  recently  show^n  such  a  tumor  primar}'  in  or  about  the 


TUMORS    OF    THE    KIDNEY 


281 


kidney,  and  in  which  distinct  gland-like  acini  and  other  unmistak- 
able epithelial  structures  were  present.^ 

As  a  rule,  in  sarcomata,  both  in  the  congenital  and  in  the  adult 
variety  as  well,  the  general  contour  of  the  kidney  is  preserved, 
although  it  is  somewhat  nodular.  In  the  early  stages,  however, 
the  growths  may  be  discrete  and  even  encysted.  Both  kidneys 
are  involved  in  a  surprisingly  large  number  of  cases.  Cystic 
sarcomata  are  relatively  frequent,  and  in  most  cases  they  are 
also  of  congenital  origin.  Round-cell,  spindle-cell,  and  mixed- 
cell  sarcomata  are  also  found  to  some  extent,  and  angiosarcomata 
and  peritheliomata  are  . 
likewise  known  to  oc- 
cur. In  some  cases  of 
lymphosarcoma,  or 
Hodgkin's  disease,  sec- 
ondary tumor-masses 
histologically  like 
those  of  true  sarcoma 
appear  in  the  kidney. 
In  a  recent  case  of  one 
of  the  writers  the 
lymphomatous  masses 
were  so  sharply  differ- 
entiated from  the  renal 
tissue  in  color  and  gross 
structure  that  they  ap- 
peared to  be  distinct 
and  well-defined  neo- 
plasms. As  with  other  secondary  tumors  of  the  kidney,  these 
growths  are  of  little  or  no  clinical  importance.  Endotheliomata 
occur  only  as  metastases. 

There  can  be  no  question  but  that  the  most  frequent  tumoi 
that  occurs  as  a  primary  growth  in  the  kidney  is  that  known 
as  the  hypernephroma,  or  the  "  struma  lipomatodes  aberratae 
renis  "  of  Grawitz.  A  careful  study  of  the  tumors  included  in 
the  series  of  Kelynack,  and  even  the  descriptions  of  renal  cancer, 
adenoma,  sarcoma,  endothelioma,  and  the  like,  cannot  but  convince 
1  "Transactions  New  York  Pathological  Society,"  March,  1908. 


Fig.  94.— Microscopic  structure  of  a  h>-pernephroma- 
Authors'  case  (see  text).  Note  varieties  in  size  and  sliape 
of  cells. 


282  TUMORS    UF    THE    KIDNEY 

one  that  many  of  these  tumors  really  belong  to  this  large  but  ill- 
defined  class  of  new-growths.  The  hypernephromata  are  said  to 
spring  from  bits  of  fetal  tissue  originally  intended  to  develop  into 
adrenal  bodies,  but  which  become  detached  and  incorporated  in 
the  anlage  for  the  kidney.  In  the  larger  number  of  cases,  un- 
doubtedly, they  remain  as  harmless  bodies  in  the  kidney  tissue, 
and  are  often  discovered  postmortem  in  the  form  of  round  or  oval 
masses  of  pinkish  or  grayish  tissue  generally  found  in  the  cortical 
portions  of  the  organs,  and  usually  well  differentiated  from  the 
remainder  of  the  renal  substance.  Microscopic  examination  of 
these  bodies  shows  them  to  be  made  up  of  columns,  sometimes 
alveoli  of  large  cells,  rich  in  protoplasm,  in  which  coarse  oil-globules 
appear.  Pigment  granules  are  often  seen.  The  close  resemblance 
these  cells  bear  to  those  of  the  adrenal  body,  particularly  to  the 
cells  of  the  zona  glomerulosa,  is  often  striking.  It  has  long  been 
customary  to  describe  such  small  growths  as  adenomata. 

Under  certain  conditions,  which  are  no  better  understood  than 
are  the  causes  of  other  neoplastic  growths,  these  islands  of  aber- 
rant tissue  begin  to  proliferate.  At  times  the  increase  in  size  is 
so  rapid  as  to  be  easily  discerned  by  a  weekh^  palpation  of  the 
abdomen.  As  an  exception  to  this  customary,  rapid  progress  may 
be  mentioned  a  case,  recently  reported  by  Richard  Weil,  in  which 
the  growth  extended  over  a  period  of  fourteen  years  before  general 
or  fatal  metastases  resulted.  The  writers  have  seen  five  cases  of 
this  growth  postmortem,  and  each  has  differed  markedly,  both 
in  clinical  and  in  anatomic  aspects,  from  the  others.  Only  in 
the  histologic  character  of  the  new-growth  could  similarity  be 
traced. 

Metastases  are  apparently  transmitted  both  by  the  lymph- 
channels  and  by  the  blood-vessels.  Those  the  result  of  direct 
extension  have  not  been  frequently  seen  in  the  writers'  experi- 
ence. As  has  been  stated  elsewhere,  the  malignancy  of  these 
tumors  and  the  rapidity  with  which  metastases  are  formed  render 
prognosis  in  these  cases  particularly  difficult.  Great  diversity  exists 
in  the  distribution  of  the  metastases.  Three  of  the  five  cases  seen 
postmortem  by  the  writers  showed  early  cerebral  metastases, 
whereas  in  one  of  the  remaining  two  the  first  discoverable  second- 
ary growth  appeared  in  the  corpora  cavernosa,  the  venous  erectile 


PLATE  VIII 


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DIAGNOSIS  283 

spaces  of  which  became,  within  a  few  weeks,  Uterally  packed  with 
tumor-cells. 

Frequently  the  primary  growth  in  the  kidney  remains  small, 
although  the  general  infection  may  be  rapid.  On  the  other  hand, 
the  tumor  mav  become  of  enormous  size,  and  the  general  infection 
be  either  slight  or  entirely  absent. 

As  is  to  be  expected  from  their  origin,  the  growths  may  occur 
either  in  youth  or  in  adult  Hfe. 

It  is  because  of  the  great  variety  of  the  histologic  pictures  pre- 
sented that  these  growths  have  frequently  been  reported  as  ade- 
nomata, carcinomata,  sarcomata,  and  epitheliomata.  It  is  indeed 
difficult  to  draw  a  picture  typical  of  a  structure  whose  chief  char- 
acteristic is  its  variabiHty,  for  in  certain  cases  the  growth 
closely  resembles  carcinoma;  in  others  it  simulates  sarcoma;  and 
occasionally  cells  resembling  syncytial  cells  are  seen.  Only  by  a 
study  of  the  structure  of  all  the  lesions  presented,  and  largely  by 
excluding  other  growths,  can  the  postmortem  diagnosis  be  made 
in  those  cases  in  which  rapid  growth  and  general  infection  have 
taken  place.  When  the  tumors  are  small  and  localized  in  the 
kidney  or  liver,  the  diagnosis  is  made  easier  from  the  close  resem- 
blance they  bear  to  the  normal  adrenal  structure. 

DIAGNOSIS 

As  has  previously  been  intimated,  in  a  considerable  number  of 
renal  tumors,  particularly  when  they  are  of  small  size,  of  slow 
growth,  or  are  situated  in  the  capsule  or  the  cortex,  diagnosis  is 
impossible.  As  a  rule,  an  early  diagnosis  of  pelvic  growths  may 
be  made  from  the  appearance  of  blood  in  the  urine,  which  is 
an  almost  constant  symptom;  and,  in  the  case  of  papillomata, 
from  the  presence,  in  the  urine,  of  bits  of  the  new-growth.  The 
chief  feature  in  the  diagnosis  obviously  is  the  presence  of  the  tumor, 
and  this  cannot,  of  course,  be  demonstrated  until  the  growth  has 
reached  a  palpable  size.  Its  renal  origin  may  be  distinguished 
by  the  usually  immovable  fixation  of  the  growth,  its  relation- 
ship to  the  kidney  region,  and  fairly  often  by  its  reniform  shape. 
The  fact  that  it  lies  posterior  to  the  intestine  can  usually  be  elicited, 
if  necessary,  by  the  inflation  of  the  gut  with  air,  and  in  some  cases 
a  more  pronounced  bulging  posteriorly  than  anteriorly  serves  as 


284  TUMORS    OF   THE    KIDNEY 

an  important  diagnostic  point.  The  lirm  and  compact  nature  of 
the  tumor  also  helps  to  distinguish  it  from  cystic  kidney.  Even 
in  those  cases  in  which  the  tumors  do  not  impinge  directly  on  the 
pelvis,  hematuria  is  generally  present.  As  a  rule,  it  occurs  peri- 
odically, although  when  the  growth  is  of  considerable  size,  or  when 
it  reaches  the  pelvis,  hematuria  may  be  a  constant  manifestation. 
In  those  cases  in  which  satisfactory  palpation  is  not  possible, 
cystoscopy  and  catheterization  of  the  ureters  may  determine 
which  is  the  diseased  side. 

As  a  rule,  there  are  no  marked  symptoms.  Pain  in  the  renal 
region,  with  a  feeling  of  weight,  may  be  complained  of.  This 
pressure  may  cause  more  or  less  venous  congestion  of  the  superfi- 
cial abdominal  or  of  the  spermatic  plexus  of  veins;  or  perhaps 
edema  of  the  lower  extremities  may  develop. 

Radiography  is  often  a  most  satisfactory  means  of  making  a 
diagnosis,  and  occasionally  a  carefully  prepared  plate  shows 
a  fairly  clearly  outlined  shadow,  and  may  indicate  the  extent 
and  location  of  the  growth  ver.y  satisfactorily  even  in  obese  sub- 
jects. 

When  metastases  have  developed,  their  distribution  and  con- 
nection with  the  direct  vascular  system  or  the  lymphatic  groups 
of  the  kidney  may  be  of  some  assistance,  although,  as  stated 
elsewhere,  the  most  frequent  renal  tumor,  the  hypernephroma,  is 
very  erratic  in  its  selection  of  points  for  metastases.  In  some 
rare  instances  the  distribution  and  nature  of  these  secondary 
growths  may  even  make  clear  the  precise  type  of  the  tumor; 
and  when  nodules  are  superficially  located,  as,  for  example,  in  the 
inguinal  lymph-nodes,  removal  of  small  bits  of  tissue  for  the  pur- 
pose of  determining  its  character  is  certainly  justifiable.  In  con- 
sidering these  renal  growths,  gumma  of  the  kidney  should  always 
be  thought  of  as  a  possibility,  although  it  occurs  but  very  rarely. 
Exploratory  operation  and  direct  palpation  of  the  kidneys  are 
often  demanded,  and,  considering  the  comparative  safety  of  these 
surgical  measures,  it  is  the  writers'  belief  that  recourse  should  be 
more  frequently  had  to  this  means  of  formulating  an  absolute 
diagnosis. 

Cachexia  may  or  may  not  be  present,  and  its  absence,  as  well 
as  the  absence  of  the  anemia  usually  accompanying  new-growths. 


GENERAL  CONSIDERATIONS   OF   TUMORS   OF   URINARY  SYSTEM    285 

is  not  to  be  considered  as  a  contraindication  that  malignancy 
exists,  since  the  sarcomata  and  hypernephromata  often  show 
the  gravest  manifestations  before  severe  cachexia  or  anemia  de- 
velops. 

The  precise  variety  of  the  growth  can  often  be  determined  only 
by  a  microscopic  examination  of  bits  of  the  affected  tissue  or  by 
inspection  of  the  involved  organs;  yet,  as  a  rule,  we  are  justified 
in  diagnosing  those  tumors  that  occur  in  early  Hfe  as  either  sar- 
comata or  hypernephromata,  whereas  those  that  appear  later  in 
life  are  either  carcinomata  or  hypernephromata. 

GENERAL  CONSIDERATIONS  OF  TUMORS  OF  THE  URINARY 
SYSTEM  AND  THEIR  TREATMENT 

Since  the  last  edition  of  this  work  many  new  methods  for  the 
study  of  malignant  growths  have  been  evolved,  and  it  has  seemed 
necessary  to  us,  even  at  the  risk  of  being  criticized  for  overstepping 
the  natural  boundaries  of  our  work,  to  consider  this  subject  as  it 
affects  the  body  as  a  whole,  for  in  that  way  only  can  we  present 
our  views  as  to  their  treatment  in  the  special  organs  considered  in 
this  work. 

Among  the  most  notable  studies  bearing  on  the  biology  of  new 
growths  are  those  on  the  inheritance  of  rat  and  mice  tumors  by 
Dr.  Louis  Loeb,  of  St.  Louis,  and  those  of  Miss  Maud  Slye  of  the 
Ortho-Sprague  Institute  of  Chicago.  Their  results  should  cer- 
tainly stimulate  surgeons  called  upon  to  deal  with  malignant 
growths  to  take,  as  a  routine,  the  most  painstaking  and  careful 
history  of  individuals  suffering  from  neoplasms  when  they  come 
under  their  care.  The  influence  of  the  Mendelian  law  in  tumor 
formation  seems  to  have  a  very  direct  and  pertinent  bearing  on 
the  study  of  all  new  growths. 

Among  the  new  methods  of  treatment  which  seem  to  promise 
real  benefit,  two  have,  within  the  last  few  years,  been  extensively 
tried  out.  These  are  treatment  by  the  x-ray  and  that  with  ra- 
dium. Growths  in  the  urinary  tract  treated  by  the  x-ray  are,  how- 
ever, few,  and  none  have  come  under  our  personal  observation, 
but  it  is  probable  that  a  field  is  opening  for  these  methods  in  the 
treatment  of  growths  of  the  bladder  and  kidney. 

We  believe  that  radium  treatment  has  come  to  stay,  either 


286  TUMORS   OF  THE   KIDNEY 

used  directly  for  the  removal  of  malignant  growths,  or  as  a  valuable 
after-treatment  following  operation.  When  there  are  no  metas- 
tases and  the  radium  is  properly  applied,  either  with  or  without 
other  operative  procedures,  we  believe  it  capable  of  curing  cancer 
in  some  few  instances.  Legueu  (Journal  d'Urologie,  19 14)  reports 
a  case  of  inoperable  carcinoma  of  the  urethra  and  vagina  in  a  young 
woman  treated  by  two  applications  of  radium,  the  second  one 
applied  several  months  after  the  first  on  account  of  recurrence  of 
the  growth,  so  strongly  as  to  give  rise  to  a  desquamation.  The 
woman  died  from  another  disease  two  years  after  the  last  applica- 
tion, and  a  most  painstaking  and  thorough  autopsy  failed  to  re- 
veal any  evidence  of  carcinoma  anywhere  in  the  system.  Two 
associates  and  a  friend  some  two  years  ago  applied  the  same  quan- 
tity of  radium  for  the  same  length  of  time  following  suprapubic 
C3^stotomies  for  malignant  growth  of  the  bladder.  One  of  the  indi- 
viduals on  whom  the  application  was  made  died  very  shortly,  the 
second  died  in  five  months  of  metastasis  of  the  kidney,  the  third 
is  apparently  entirely  well,  and  has  gained  some  30  pounds  in 
weight.  These  cases  are  mentioned  as  illustrating  oiur  views  con- 
cerning what  can  be  expected  in  the  use  of  radium. 

Concerning  the  application  of  radium  in  bladder  tumors  under 
ordinary  circumstances  we  are  inclined  to  believe  the  most  prac- 
tical method  is  to  open  the  bladder  and  apply  the  emanations  di- 
rectly to  the  growth,  or  to  the  seat  of  the  growth  after  it  has  been 
removed. 

Internal  Treatment. — Malignant  growths  of  all  locations  are  so 
dependent  on  general  conditions  that  it  seems  they  may  be  bene- 
ficially influenced  and  life  prolonged  by  the  persistent  and  constant 
carrying  out  of  every  logical  procedure,  hygienic  or  medicinal. 
Tonics,  particularly  those  which  seem  to  increase  oxidation,  such 
as  manganese  and  iron  in  as  large  doses  as  can  well  be  borne,  ar- 
senious  acid  in  some  form,  and  the  prolonged  ingestion  of  various 
bitters,  inunctions  of  such  as  echinacea,  are  probably  of  some  ben- 
efit. Apparently  the  selenium  salts  have  some  effect  in  diminish- 
ing pain,  and  perhaps  tend  to  make  malignant  tissue  break  down. 
Probably  of  more  value  is  the  administration  of  -^  grain  three 
times  daily  of  the  sulphocyanid  of  selenium  in  an  alkaline  media; 
it  can  safely  be  given  internally  for  four  or  five  days  with  equal 


GENERAL   CONSIDERATIONS   OF   TUMORS   OF   URINARY  SYSTEM   287 

intermissions  between.  A  curious  fact  to  be  noted  here  is  that, 
acting  on  the  suggestion  of  Dr.  H.  W.  Fetzer,  the  examination  of  a 
large  number  of  samples  of  urine  from  our  cancer  patients  by  the 
chemist,  John  Killian,  has  shown  they  all  contain  a  large  increase 
in  the  amount  of  neutral  sulphur.  While  the  persistent  use  of  such 
general  treatments  is  advocated  by  us  and  is  recognizably  only  em- 
piric, in  our  observation  general  measures  are  too  often  neglected 
in  the  treatment  of  new  growths  by  all  physicians. 


CHAPTER  XVI 

THE  SURGERY  OF  THE  KIDNEY 

The  examination  of  the  kidney  for  diagnostic  purposes  has  been 
discussed  in  previous  chapters.  To  repeat,  percussion  and  bal- 
lottement  over  the  kidney  area  may  give  useful  information. 
Bimanually,  the  kidney  region  should  be  examined  by  having  the 
patient  lie  on  his  back  on  a  table,  with  the  legs  drawn  up,  one 
hand  of  the  surgeon  being  placed  under  the  back  in  the  space  be- 


Fig-  9S- — Bimanual  examination  of  the  kidney. 

tween  the  border  of  the  last  rib  and  the  crest  of  the  ilium,the  other 
hand  occupying  the  corresponding  space  over  the  abdomen  in 
front.  The  kidney  may  thus  be  examined  between  the  two  hands, 
the  surgeon  increasing  pressure  as  the  patient  exhales,  the  abdom- 
inal muscle  being  contracted  as  little  as  possible.  Another 
similar  procedure  is  that  of  having  the  patient  lie  over  a  table  or 
chair,  the  kidney  being  felt  for  bimanually,  in  the  manner  previ- 
ously directed.      It  has  been  stated  that  in  cases  of  pelvic  tumors 


THE    SURGERY    OF    THE    KIDNEY 


289 


if  the  pelvis  is  elevated,  the  tumor  tends  to  fall  toward  the  source 
of  its  origin,  and  that  by  this  method  a  differential  diagnosis  may 
be  made  between  a  tumor  of  the  kidney  and  one  of  some  other 
organ.  The  writers  have  not  found  this  procedure  of  any  value. 
It  has  been  their  experience  that,  for  the  physical  examination 
of  the  kidney  bimanually,  that  method  with  which  the  surgeon 
is  most  familiar  will  yield  the  most  information;  that  the  ease 
with  which  information  can  be  acquired  by  physical  examination 


Fig.  96. — Examination  of  kidney  with  patient  lying  on  side. 

is  very  much  increased  by  practice.  Now  that  a  keener  interest 
has  been  awakened  in  determining  the  physical  condition  of  the 
kidneys,  it  is  to  be  hoped  that  the  general  practitioner  will  examine 
the  kidneys  bimanually  as  a  matter  of  routine  more  frequently 
than  was  done  in  the  past.  Kidney  dissections  and  operations  on 
the  cadaver  are  of  particular  value  in  familiarizing  one  with  the 
situation  and  surroundings  of  these  organs.  In  spite  of  the  various 
aids  to  diagnosis  previously  mentioned,  some  surgical  conditions 
will  remain  in  doubt  until  the  question  be  solved  by  an  explor- 
atory operation.  This  is  particularly  true  of  tumors  of  the  kid- 
ney, and  more  especially  of  those  tumors  that  are  either  on  or 
connected  with  the  organ,  and  yet  interfere  so  little  with  the  kidney 
function  that  information  cannot  be  obtained  by  means  of  urinary 
examination  or  ureteral  catheterization.  This  is  not  infrequently 
the  case  when  there  is  a  question  of  stone  or  of  tuberculosis. 
19 


>90 


THE    SURGERY    OP   THE    KIDNEY 


The  method  of  massage  of  the  kidney  region,  as  given  in  detail 
in  the  article  on  "Suppurative  Nephritis"  earher  in  the  volume, 
will  be  found  to  be  a  most  useful  and  practical  procedure  for  de- 
termining whether  a  pus  kidney  may  or  may  not  be  present. 

In  this  chapter  the  following  operations  will  be  considered: 
(i)  The  operation  for  the  exploration  of  the  kidney.  (2)  Neph- 
ropexy, the  operation  of  anchoring  a  displaced  kidney.  (3)  Neph- 
rotomy, the  operation  of  opening  the  kidney  for  abscesses,  stone, 
and  similar  conditions.  (4)  Nephrectomy,  the  operation  of  re- 
moving the  kidney,  either  in  whole  or  in  part.  (5)  The  operation 
for  performing  decapsulation  of  the  kidney.       (6)  Operations  for 


Fig-  Q7- — A,  Loin   incision;    V.,   Hdebohls'  incision;  C,         Fig.    98. — Showing    continuatiorr 
Israel's  incision  ;  D,  transverse  incision.  of  Israel's  incision. 

the  treatment  of  Bright's  disease.      (7)   The  operation  for  per- 
forming lavage  of  the  pelvis  of  the  kidney. 


OPERATIONS   FOR   EXPLORATION   OF   KIDNEY 


291 


OPERATIONS  FOR  THE  EXPLORATION  OF  THE  KIDNEY 
The  incision  through  the  loin  is  the  one  that  is  ordinarily  recom- 
mended for  exploring  the  kidney.  The  following  is  the  descrip- 
tion of  the  operation  as  laid  down  in  the  standard  text-books, 
with  supplementary  remarks  as  to  such  special  details  as  have 
proved  most  satisfactory  in  the  hands  of  the  writers. 


(  © 


Fig.  gg. — Illustrating  the  "  Mayo  "  attachment  to  surgical  table  for  operations  on  the  kidney. 


Fig.  100.— Edebohls'  pad  for  operations  on  kidney. 


Before  making  the  incision  in  the  loin,  the  patient  is  placed  upon 
the  side  opposite 
the  one  that  is  to 
be  incised.  The 
flank  to  be  operated 
upon  is  elevated  by 
sand-bags  or,  bet- 
ter, by  placing  an 
Edebohls  bag  under  the  opposite  side.  The  guiding  points  are  the 
twelfth  rib,  the  crest  of  the  ilium,  and  the  external  border  of  the 
erector  spinae  muscle.  The  incision  should  be  begun  about  half  an 
inch  below  the  twelfth  rib,  close  to  the  border  of  the  erector  spinae, 
and  descend  obliquely  downward  and  forward  until  it  is  about  a 
finger's  breadth  from  the  crest  of  the  ilium.  (This  incision  is  shown 
in  the  illustration,  fig.  loi.)  After  dividing  the  skin,  the  superfi- 
cial fascia,  fat,  and  the  latissimus  dorsi,  the  internal  border  of  the 
external  oblique  muscle  is  exposed.  Being  incised,  the  internal 
oblique  and  the  posterior  aponeurosis  of  the  transverse  muscle  are 


292 


THE   SURGERY   OF   THE    KIDNEY 


laid  bare.  Cutting  through  the  aponeurosis,  the  yellow  fat  of  the 
perirenal  tissues  appears  in  the  fatty  capsule.  This  fat  is  much 
more  evident  on  the  posterior  than  on  the  anterior  surface  of  the 
kidney.     At  times  it  resembles  the  peritoneum. 

The  fatty  capsule  being  reached,  it  should  be  carefully  opened 
on  the  directer  for  an  inch  or  more,  the  finger  inserted,  which 
should  gradually  break  down  the  adhesions  which  exist  between 
the  fatty  capsule  and  the  true  capsule  of  the  kidney.  Ordinarily 
but  little  difficulty  is  experienced,  which  is  apt  to  be  most  marked 
at  the  poles.  When  both  poles  of  the  kidney  are  freed  from  the 
fatty  capsule,  the  freeing  of  the  remainder  of  the  kidney  is  a  com- 


'^^'■'■'■'1   -■dim  ^fi'" 


Fig.  loi. — Ordinary  exploratory  loin  incision  for  exposing  the  kidney. 


paratively  easy  matter.  The  kidney,  having  been  freed  from  the 
fatty  capsule,  can,  provided  it  is  not  too  large,  be  lifted  up  into 
the  wound  and  its  general  appearance  observed.  Particularly 
is  it  necessary  to  carefully  palpate  the  pelvis  of  the  kidney  and 
ascertain  as  much  as  possible  concerning  its  condition.  Natur- 
ally, should  the  operator  prefer,  the  kidney  may  be  reached  through 
the  Ebebohl's  incision  or  through  a  laparotomy  incision.  It 
should  be  borne  in  mind  that  kidneys  not  infrequently  normally 
vary  somewhat  in  shape  and  size.  The  shape  of  a  kidney  being 
slightly  different  from  the  usual  may  not  necessarily  mean  that 
the  kidney  is  diseased.     The  operator  not  being  content  with  the 


OPERATIONS   FOR   EXPLORATION   OF   KIDNEY  293 

manual  examination  of  the  kidney,  in  order  to  ascertain  fully 
the  condition  of  its  interior,  should  next  decide  the  incision  to  use 
in  the  particular  case.  It  is  a  comparatively  eas)''  matter,  a 
compression  being  made   on   the  pedicle   of   the   kidney   by   an 


Fig.  102. — Illustrating  loin  incision  for  exploration  of  the  kidney.      Appearance  after  incision  of 
skin  and  fatty  cellular  tissue. 

assistant,  to  control  the  hemorrhage  from  the  kidney,  or  a  pedicle 
clamp  may  be  used  protected  by  a  rubber  cover.  The  procedure 
of  puncturing  the  kidney  with  needles,  often  used  in  the  past, 
is  gradually  going  out  of  use,  and  exploratory  incisions  into  the 


Fig.  103. — After  section  of  latissimus  dorsi.      Cross  showing  position  of  incision  of  the   aponeu- 
rosis of  the  transverse  muscle. 

kidney  tissue  are  coming  more  and  more  into  vogue.  If  a  stone 
can  be  felt  or  an  abscess  or  tumor  is  causing  any  bulging  of  the 
tissue,  the  place  of  incision  of  the  kidney  will  be  indicated  by  the 


294  the;  surgery  of  the  kidney 

prominence.  No  particular  spot  being  indicated,  it  is  necessary 
to  explore  the  kidney.  It  is  particularly  advisable  when  making 
an  incision  into  the  kidney  to  make  one  that  will  either  directly 
or  indirectly  lead  to  the  pelvis  of  the  kidney,  and  for  that  purpose 
the  incision  recommended  by  Albarran,  a  picture  of  which  is  given 
(fig.  1 08) ,  will  be  found  the  most  useful .  This  incision,  to  commence 
with,  is  about  three-quarters  of  an  inch  deep  and  leads  toward  the 
lower  calix  of  the  kidney.  By  means  of  dilatation  with  the  scis- 
sors the  opening  should  be  enlarged  so  as  to  permit  the  finger  to 
penetrate,  then,  without  tearing  apart  the  renal  tissue,  through  it 
the  finger  can  gradually  make  its  way  into  the  pelvis  of  the  kidney. 
If  this  incision  should  not  be  feasible,  the  so-called  "postmor- 
tem "  incision,  of  which  an  illustration  is  given  (fig.  109),  maybe 
employed.  After  the  kidney  has  been  explored  the  incision  should 
be  sutured  with  No.  2  catgut.  If  pus  has  been  fotmd  in  the  ex- 
ploration, a  small  drainage-tube  should  be  inserted  well  down  in 
the  pelvis  of  the  kidney,  and  the  wound  sewed  up  around  the 
tube.  If  any  decapsulation  has  been  performed  during  the  opera- 
tion, care  should  be  taken  that  part  of  the  true  capsule  be  left 
around  the  incision  to  help  hold  the  stitches. 

It  is  being  suggested  of  late,  in  certain  conditions  where  the  kid- 
neys are  being  explored,  that  it  is  well  to  resect  a  portion  of  any 
tumor,  or  of  the  parenchyma  of  the  kidney  in  certain  cases,  and 
have  a  quick  microscopic  examination  made  which  should  give  aid 
in  the  diagnosis.  Such  procedures,  unfortunately,  are  at  present 
to  some  extent  more  of  a  theoretic  than  they  are  of  practical 
value.  The  reason  is  that  while  the  hasty  examination  in  cer- 
tain cases  may  be  of  benefit,  in  such  conditions  as  tumors  of 
mixed  form,  quite  a  prolonged  examination  will  be  necessary  in 
order  to  determine  the  nature  of  the  growth. 

NEPHROPEXY 

In  performing  the  operation  for  fixation  of  movable  or  floating 
kidney  the  patient  should  be  placed  on  the  abdomen  over  a  sand- 
bag or  an  Bdebohls  pad.  Make  an  incision  that  starts  about  two 
and  one-half  inches  from  the  spine,  extending  from  the  lower 
border  of  the  twelfth  rib  to  the  crest  of  the  iUum,  •  and  nearly 
parallel  with  the  spine.     The  inventor  of  this  incision  suggests 


NEPHROPEXY 


295 


that  if  this  does  not  give  room  enough,  the  outer  margin  of  the 
quadratus  lumborum  be  nicked,  very  near  its  insertion  into  the 
crest  of  the  iHum.  An  incision  is  made  through  the  muscles  until 
the  perirenal  fat  is  reached,  and  carried  through  this  until  the 
capsule  of  the  kidney  is  exposed;  the  patient's  feet  are  then  seized 
and  the  body  drawn  toward  the  foot  of  the  table.  The  Edebohls 
pad,  well  inflated,  is  thus  brought  under  the  margin  of  the  lower 
ribs,  and  tends,  in  most  cases,  to  press  the  organ  up  through  the 
incision  and  thus  aid  in  exposing  its  posterior  aspect. 

It  is  difficult  to  advise  as  to  the  best  method  of  anchoring  the 
kidney.     The  various  operators  all  have  different  views  on  the 


Fig.  104. — The  aponeurosis  of  the  transverse  muscle  having  been  incised. 

subject,  and  to  make  the  matter  still  more  confusing,  from  time 
to  time  these  -views  are  modified  and  different  methods  suggested 
from  those  previously  practised.  Generally  speaking,  the  opera- 
tion of  anchoring  the  kidney  in  its  proper  position  used  at  present 
consists  in  one  of  two  methods — that  in  which  the  sutures  are 
placed  through  the  true  kidney  tissue,  and  that  in  which  they  are 
placed  through  the  true  capsule  of  the  kidney.  There  are  various 
modifications  of  these  methods,  based  on  whether  the  capsule 
should  be  removed  entire  or  in  part.  The  evidence  is  very  con- 
vincing as  to  the  permanent  retention  of  the  kidney  in  this  position 
after  fixation  by  the  method  advised  by  Dr.  George  M.  Edebohls 
and  described  by  him  in  an  article  entitled   "  The  Technics   of 


296 


THE   SURGERY   OF   THE    KIDNEY 


Nephropexy  as  an  Operation  per  se  and  as  Modified  by  Combina- 
tion  with    Lumbar    Appendicectomy    and    Lumbar    Exploration 


Fig.  105. — Edebohls'  incision  for  exposing  tlie  kidney. 


Fig.   106. — Showing   method   of  introducing   sutures   into   exposed  kidney,  capsule  having  been 

rolled  back  (Edebohls). 

of  the  Bile-passages,"  "Annals  of  Surgery,"  February,  1902.    His 
method  is  practically  as  follows: 


NEPHROPEXY  297 

The  kidney  having  been  exposed  through  the  incision  previously 
mentioned,  and  freed,  so  far  as  necessary,  by  blunt  dissection,  is 
delivered  through  the  wound  on  to  the  back.  The  fatty  capsule 
is  dissected  off  so  as  to  expose  the  capsule  proper  through  its  entire 
extent,  and  the  kidney  palpated.  The  iliohypogastric  nerve  is 
drawn  to  one  side  out  of  reach  of  injury.  If  this  cannot  be  done, 
and  the  nerve  must  be  divided,  reunite  the  severed  ends  with  cat- 
gut after  anchoring  the  kidney  and  before  closing  the  wound. 
Then  a  nick  is  made  in  the  capsule  proper  near  the  middle  of  its 
convex  border,  large  enough  to  admit  the  tip  of  a  grooved  director, 
and  upon  it  the  capsule  proper  is  divided  along  the  entire  length 
of  the  convex  border  of  the  kidney  to  a  point  half-way  between 
the  upper  and  lower  poles  of  the  organ,  and  the  capsule,  by  blunt 
dissection  on  each  side  of  the  incision,  is  reflected  forward  and 
backward  toward  the  renal  pelvis  to  a  point  about  midway  be- 
tween the  external  and  internal  borders  of  the  kidney.  This  will 
leave  one-half  of  the  kidney  denuded,  the  capsule  being  turned 
back  upon  it  like  the  lapel  of  a  coat.  Two  sutures  are  then  placed, 
as  is  shown  in  the  illustration  (fig.  106)  on  the  anterior  surface  of 
the  kidney — one  at  the  middle  of  the  upper  and  one  at  the  middle 
of  the  lower  half  of  the  organ.  Two  other  sutures  are  placed  at 
corresponding  points  on  the  posterior  surface  of  the  kidney. 
Each  suture  runs  parallel  to  the  long  axis  of  the  kidney,  and  is 
passed  through  the  reflected  capsule  close  to  the  line  of  the  reflec- 
tion, then  through  the  underlying  attached  capsule,  and  runs  along 
beneath  the  latter  between  the  capsule  and  the  kidney  substance  for 
a  distance  of  two  or  three  centimeters,  when  it  again  emerges  through 
the  attached  and  reflected  layers  of  the  capsule.  A  Hagedorn 
needle  with  a  broad  surface  should  be  used,  running  it  flatwise 
between  the  capsule  proper  and  the  kidney  substance  to  avoid 
penetration  of  the  latter.  These  sutures  are  then  brought  out  to 
and  through  the  muscles,  but  not  through  the  skin,  to  a  position 
corresponding  to  that  in  which  they  have  been  inserted.  The 
wounds  of  the  muscles  and  fascia  are  closed  by  from  four  to  six 
sutures  of  forty-day  catgut,  passed  in  such  a  manner  as  to  turn 
the  raw  surface  of  the  quadratus  lumborum  toward  the  exposed 
kidney  surface.  This  is  effected  by  suturing  the  latissimus  dorsi 
and  the  lumbar  fascia  forming  the  outer  lips  of  the  wound  to  the 


298  THE   SURGERY    OF   THE    KIDNEY 

latissimus  dorsi,  the  sheath  of  the  erector  spinae,  and  the  outer  hp 
of  the  open  sheath  of  the  quadratus  lumborum  at  the  inner  mar- 
gin of  the  incision.  Then  the  eight  ends  of  the  fixation  sutures 
are  drawn  tight  so  as  to  bring  the  denuded  aspect  of  the  kidney 
in  contact  with  the  raw  surface  of  the  quadratus  lumborum,  and 
the  two  ends  of  each  of  the  four  suspension  sutures  are  tied  to  one 
another.  The  suspension  and  muscle  sutures  are  buried  by  clos- 
ing the  skin  over  them  with  the  intracuticular  suture.  By  this 
method  the  denuded  cortex  of  the  outer  half  of  the  kidney  is  in 
snug  contact  with  the  raw  quadratus  lumborum  through  the 
entire  length  of  the  latter  from  rib  to  ilium.  The  dressing  is 
placed  across  the  entire  width  of  the  back  smoothly  and  evenly. 

Since  a  small  kidney  can  be  well  exposed  through  this  w^ound, 
the  Edebohls  incision  is  often  best  where  stone  is  suspected. 
The  small  kidney  can  be  removed  through  this  incision,  but  where 
the  organ  is  large,  or  a  large  abscess  is  present,  or  a  graver  condi- 
tion exists,  such  as  a  suspected  malignant  growth,  one  of  the  other 
incisions  more  ordinarily  used  for  nephrectomy^  or  nephrotomy 
had  better  be  employed.  If,  however,  after  making  the  Edebohls 
incision  as  described  it  should  prove  insufficient,  and  a  larger  one 
be  required,  one  of  the  other  kidney  incisions  may  be  employed; 
or,  as  an  adjunct  to  this,  if  necessary,  the  opening  can  be  made 
much  larger  than  is  ordinarily  required. 

This  operation,  or  some  modification  of  it,  is  the  one  recom- 
mended by  the  writers  for  the  use  of  those  operators  who  do  not 
fear  the  after-effects  of  an  adhesive  inflammation  that  takes  place 
between  the  kidney  surface,  when  it  is  denuded  of  its  cortex,  and 
the  muscles.  It  must  be  remembered,  in  this  connection,  that 
it  is  the  adhesive  inflammation  that  holds  the  kidney  in  place. 
At  the  present  time,  cases  are  being  reported  in  which  to  anchor 
the  kidne}^  the  stitches  are  taken  through  the  true  capsule  and  kid- 
ney tissue.  As  a  result  of  passing  ligatures  through  the  kidney 
tissue,  lines  of  scar  tissue  are  formed,  following  the  track  in  which 
the  ligatures  are  placed. 

If  it  is  desired  to  anchor  both  kidneys,  the  same  procedure  as 
that  outUned  may  be  followed,  anchoring  one  organ  after  the 
other  has  been  secured.  Or,  if  it  is  desired,  through  the  Edebohls 
incisions  made  on  each  side  of  the  erector  spinge,  both  kidneys 


NEPHROTOMY 


299 


may  be  brought  through  the  wound  and  exposed,  for  purposes 
of  comparison. 

Albarran  ^  recommends,  in  anchoring  a  displaced  kidney,  if  any 
hydronephrosis  is  present,  the  kidney  be  retained  in  such  a  posi- 
tion as  to  bring  the  ureteral  opening  at  the  most  dependent  part 
of  the  sac. 

NEPHROTOMY 

This  term  is  used  so  generally  that  it  comprises  very  often  the 
exploratory  incision  just  described  as  well  as  the  continuation 
of  such  incision  for  a  specific  purpose,  such  as  the  removal  of 
calcuH  or  the  drainage  of  a  pus-cavity. 


Fig.  107. — Method  of  attaching  edges  of  liidney  poclcet  to  the  abdominal  wall  (nephrostomy). 

In  performing  this  operation  in  the  past  it  has  been  customary 
to  employ  the  loin  incision  previously  described.  If  the  operation 
is  done  simply  to  open  a  pus  cavity,  the  kidney  should  be 
freed  and  brought  as  far  up  into  the  wound  as  possible,  carefully 
palpated,  and  an  incision  made  into  the  most  fluctuating  portion 
of  the  mass.  After  this  has  been  done  and  the  pus  has  been  allowed 
to  escape,  the  cavity  should  be  cleansed,  a  drainage-tube  inserted 
to  the  bottom  of  the  wound,  and  the  muscles  and  skin  sutured  on 
each  side  as.far  as  the  tube.     After  a  few  days  the  tube  may  be  re- 

1  "  Transactions  Assoc.  Francais  Urologie." 


300 


THE    SURGERY    OF   THE    KIDNEY 


moved  and  a  smaller  one  introduced,  or  the  wound  be  packed 
with  gauze,  which  should  gradually  be  removed.  By  splitting 
the  capsule  of  the  kidney,  pushing  it  back  a  little  on  each  side, 
and  then  suturing  the  capsule  to  the  walls  of  the  wound  a  pocket 
is  formed  at  the  bottom  of  the  wound,  which  may  be  kept 
open    for    observation    as   long    as    may    seem    desirable.      The 


Fig.  io8. — Showing  exploratory  incision  on   posterior  surface  of  kidney   (redrawn  from 

Albarran). 

French  have  applied  the  term  net>hr ostomy  to  this  procedure. 
If  this  operation  is  performed  for  the  purpose  of  releasing  infected 
urine  from  the  kidney,  rather  than  for  simply  effecting  drainage 
of  a  pus-cavity,  Albarran  advises  that  drainage  be  instituted 
by  the  natural  route  in  the  following  manner: 

He  catheterizes   the  ureter  before  the  operation  with  a  small 
ureteral  sound  introduced  into  the  ureter  as  far  as  it  will  penetrate. 


NEPHROTOMY 


301 


After  the  kidney  is  opened,  it  is  easy  to  make  this  sound  penetrate 
into  the  pelvis  of  the  kidney ;  then  a  larger  sound  may  be  attached 
to  this  one  and  pulled  down  through  until  a  No.  10  or  11  catheter 
can  be  passed.     The  first  sound  that  is  passed  by  the  aid  of  a 


Fig.  lOQ. — Kidney  having  been  delivered  through  opening,  assistant  compressing  pedicle;  illustrat- 
ing the  so-called  postmortem  incision  for  exploration  of  kidney. 

cystoscope  is  generally  a  Xo.  6.  WTien  the  end  of  the  large  ureter 
catheter  has  reached  a  suitable  place  in  the  kidney,  it  may  be 
fastened   there  by  means  of  a  ligature  running  out  through  the 


Fig.  no. — Showing  method  of  applj-ing  clamp  to  pedicle  when  impossible  to  dehver  kid- 
ney through  opening  (Berger  and  Hartmann). 

lumbar  opening,  the  other  end  of  the  sound,  of  course,  protruding 
from  the  urethra.  To_  remove  the  catheter  it  is  only  necessar}'' 
to  cut  the  thread  and  withdraw  the  catheter  through  the  meatus. 


302 


THE   SURGERY   OF   THE    KIDNEY 


Edebohls'  incision  may  be  used  in  performing  nephrotomy  when 
the  kidney  is  not  too  large  and  there  is  a  large  space  between  the 
twelfth  rib  and  the  crest  of  the  ilium. 


% 

p- 

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Mfwrigl^.  'jrt"^>  ^     -"^  / 

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- 

Fig.  HI. — Ureter  ligated,  separate  ligation  of  blood-vessels  (Berger  and  Hartmann). 

When  the  operation  of  nephrotomy  is  performed  for  the  removal 
of  stone,  the  kidney  should  be  isolated  as  much  as  possible  and 
brought  well  up  into  the  wound.    A  temporary  ligature  should  be 


p 

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^^^ 

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^^ 

-B-., 

Fig.   112. — Ligation  of  ureter,  kidney  delivered  through  opening  (Berger  and  Hartmann). 

placed  around  the  portion  of  the  kidney  that  joins  the  ureter, 
thereby  compressing  the  artery,  or  that  portion  of  the  kidney  may 
be  compressed  between  the  thumb  and  forefinger  of  the  assistant. 


NEPHRECTOMY  303 

If  a  stone  can  be  outlined,  it  can  be  cut  down  upon  and  removed, 
hemorrhage  checked,  and,  if  necessary,  a  few  Hgatures  placed  in 
the  kidney  substance.  If  the  presence  of  stone  is  known,  but  can- 
not be  positively  located,  the  Albarran  incision  or  some  modifi- 
cation of  it  should  be  made  into  the  kidney  and  a  search  of  the 
kidney  made,  or,  if  necessary,  the  "  postmortem  incision,"  pre- 
viously mentioned,  may  be  used.  When  the  stone  has  been  found 
it  should  be  seized  between  forceps  designed  for  the  purpose  and 
removed;  or,  if  closely  encapsulated  in  the  calices  of  the  kidney, 
it  may  be  removed  with  a  curet.  If  the  stone  is  very  large  and 
extends  in  various  directions  the  incision  may  be  prolonged 
in  the  direction  of  the  stone,  which  can  be  broken  up  with  forceps 
and  the  fragments  removed. 

After  a  stone  has  been  removed,  others  should  be  searched  for 
in  the  calices  of  the  kidney.  Retrograde  catheterization  of  the 
ureter  with  an  elastic  bougie  should  then  be  performed,  in  order 
to  determine  that  the  ureteral  canal  is  unobstructed.  These 
various  procedures  having  been  carried  out,  the  wound  in  the 
kidney  should  be  sutured  with  two  sets  of  sutures — a  deep  and  a 
superficial  set;  the  compression  of  the  pedicle  of  the  kidney  may 
now  be  removed,  the  capsule  of  the  kidney  sutured,  and  the  inci- 
sion in  the  wall  closed,  with  the  exception  of  a  short  space  in  the 
lower  portion  of  the  wound,  where  a  small  drain  may  be  placed 
for  forty-eight  hours.  Some  advocate,  for  the  removal  of  stone, 
opening  the  ureters  just  below  the  pelvis  of  the  kidney — an  opera- 
tion known  as  pyelotomy.  If  this  is  done,  the  pelvis  of  the  kidney, 
easily  accessible,  may  be  examined  through  this  opening  by  the 
finger  and  the  stone  extracted;  afterward  the  wound  should  be 
sewed  up  and  a  drainage-tube  inserted  for  a  day  or  two,  in  case 
urinary  leakage  should  take  place.  If  practicable,  a  still  better 
plan  in  these  cases  is  to  insert,  in  addition  to  the  drainage-tube 
left  in  the  incision,  a  ureteral  catheter,  introduced  through  the 
urethra. 

NEPHRECTOMY 

Nephrectomy  is  the  operation  by  which  the  kidney  is  removed 
entirely  or  in  part.  The  ordinary  loin  incision,  as  described  in 
the  operation  of  nephrotomy,  is  the  one  ordinarily  employed  for 


304  THE    SURGERY    OF   THE    KIDNEY 

this  purpose,  together  with  resection  of  a  rib  or  a  supplementary 
incision,  if  necessary,  to  obtain  the  proper  amount  of  room.  This 
procedure  resembles  the  operation  for  nephrotomy  just  men- 
tioned, until  the  kidney  itself  has  been  reached.  The  opera- 
tion is  comparatively  easy,  provided  the  kidney  has  not  been  very 
much  increased  in  size  and  has  many  adhesions  through  some 
inilammatory  condition,  which  may  exist  either  in  or  around  it 
or  both.  The  great  difficulty  in  performing  this  operation  is 
to  well  isolate  the  pedicle,  and  to  be  sure  that  all  the  blood-vessels 
and  the  ureter  are  well  ligated.  The  adhesions  so  apt  to  exist 
in  the  kidney  necessitating  nephrectomy  sometimes  render 
this  procedure  very  difficult.  The  adhesions  having  been  broken 
up  as  well  as  possible,  the  pedicle  of  the  kidney  having  been 
carefully  gone  over  by  the  examining  finger,  the  decapsulation 
of  the  fatty  capsule  having  been  carefully  performed,  bearing 
in  mind  that  the  ureter  is  toward  the  bottom  of  the  opening,  an 
attempt  should  be  made  to  isolate  it  and  tie  it  between  two  silk 
ligatures.  The  ligature,  the  incision  having  been  completed,  * 
which  holds  the  severed  ureter  as  separated  from  the  kidney 
should  be  left  long  to  facilitate  further  examination  of  the  ureter. 
An  attempt  should  then  be  made  to  deliver  the  kidney  through  the 
opening  on  to  the  loin.  A  double  catgut  ligature  should  be  run 
through  the  middle  of  the  pedicle  so  as  to  divide  it  in  half  and 
each  half  tied  separately.  A  well-fitting  clamp  should  be  placed 
above  these  ligatures  and  the  kidney  removed  above  the  clamp. 
The  ligatures  should  be  left  long  which  have  tied  the  pedicle, 
and  for  the  sake  of  safety  another  ligature  should  be  placed  around 
the  entire  pedicle  before  the  clamp  is  removed.  Catgut  No.  2  is 
sufficiently  large  for  these  ligatures.  The  severed  end  of  the 
ureter  should  then  be  brought  up  into  the  wound,  the  ligature 
which  controls  it  opened,  and  the  permeability  of  the  ureter 
ascertained  through  the  passing  of  a  probe.  The  end  of  the  ureter 
can  then  be  religated  and  cauterized  with  the  actual  cautery  or 
a  drop  of  carbolic  acid.  If  more  space  is  required,  <-he  operator 
should  not  hesitate  to  enlarge  his  original  incision  in  the  direction 
seemingly  most  desirable,  so  that  the  kidney  may  be  well  brought 
up  into  the  wound,  pushing  before  him,  when  possible,  the  perito- 
neum if  it  is  reached. 


NEPHRECTOMY 


305 


It  is  recommended  that,  whenever  possible,  the  blood-vessels  and 
ureters  be  tied  off  separately,  and  in  tubercular  cases  it  is  wise  to  tie 
off  the  ureter  as  low  down  as  practicable,  and  not  to  forget  to  cau- 
terize the  end  of  the  ureter  left  behind  with  a  solution  of  carbolic 
acid,  after  which  it  should  be  wiped  off  with  alcohol.  The  passage  of 
a  bougie  into  the  ureter  lends  some  aid  in  isolating  it.  If  it  is  not 
practicable  to  separate  the  pedicle,  so  that  the  ureters  and  blood- 
vessels can  be  tied  off  separately,  a  ligature  can  be  placed  about  the 
entire  pedicle.  In  some  cases  it  is  so  difficult  to  get  at  the  pedicle 
that  it  may  be  advisable  to  leave  clamps  in  place  in  the  wound  for 
twenty-four  hours. 
Ordinarily,  after  the 
kidney  has  been  re- 
moved, the  wound 
may  immediately  be 
closed  if  no  pus  has 
been  present.  If  the 
condition  is  a  sup- 
purating one,  more 
or  less  inflammatory 
infiltration  taking 
place  into  the  sur- 
rounding tissues,  it 
is  advisable  to  leave 
the  wound  open  and 
allow  drainage  to 
take  place  from  a 
small  opening  at  the 

lower  angle.  In  suturing  the  wound  after  nephrectomy,  when- 
ever practicable,  three  sets  of  sutures  should  be  employed — a 
deep  set  for  the  deeper  muscles,  a  middle  set,  and  a  superficial  set. 

Abdominal  or  Transperitoneal  Nephrectomy 

The  ordinary  median  incision,  such  as  is  used  in  making  an 
exploratory  laparotomy,  is  also  employed  for  effecting  removal  of 
the  kidney,  or  an  incision  may  be  made  a  little  to  the  left  or  right  of 
and  parallel  to  the  median  line,  as  the  operator  may  see  fit.  Pro- 
ceed as  in  the  case  of  exploratory  laparotomy,  until  it  becomes 


Fig.  113. — Showing  curved  line  of  incision  in  posterior 
peritoneal  wall  to  avoid  injury  to  blood-supply  of  colon  in 
abdominal  nephrectomy  (Hartmann). 


3o6  THB   SURGERY  OF  THE   KIDNEY 

necessary  to  incise  the  dorsal  reflection  of  the  peritoneum.  When 
this  has  been  done,  the  transversaUs  and  fat  should  also  be  incised, 
when  the  kidney  will  be  reached;  if  any  adhesions  exist,  they 
should  be  broken  up,  the  kidney  deUvered  through  the  abdominal 
opening,  and  the  pedicle  tied  off  as  in  extraperitoneal  nephrec- 
tomy. The  opening  in  the  posterior  peritoneal  wall  should  next 
be  closed,  and  then  the  corresponding  opening  in  the  anterior  peri- 
toneal wall  should  be  sutured. 

Much  has  been  written,  particularly  in  France,  about  the  dan- 
ger of  injuring  the  blood-supply  to  the  colon,  and  in  order  to 
overcome  this,  some  surgeons  advocate  the  making  of  a  cmved 
incision  in  the  posterior  peritoneal  wall,  outside  and  parallel  to 
the  colon,  as  shown  in  the  illustration  (fig.  1 13).  It  is  the  practice 
of  some  operators  to  estabhsh  coimterdrainage  of  the  postperitoneal 
pocket,  the  place  formerly  occupied  by  the  kidney,  by  making  a 
counteropening  through  the  loin. 

Partiai,  Nephrectomy 

The  practice  of  removing  portions  of  the  kidney  the  seat  of 
traumatism  or  benign  tmnors  is  increasing.  The  operation  is, 
of  course,  essentially  nephrectomy,  except  that  only  a  portion 
of  the  kidney  tissue  is  removed.  Hemorrhage  must  be  careftdly 
checked,  and  the  edges  of  the  kidney  woimd  then  brought  together 
with  one  or  two  sets  of  Lembert  sutures. 

Although  many  of  these  operations  are  constantly  being 
reported,  sufficient  time  has  not  elapsed  to  attest  the  value  of  this 
procedure.  Some  compensatory  kidney  hypertrophy  takes  place, 
and  a  considerable  portion  of  the  kidney  maj^  be  removed,  and 
the  remainder  of  the  organ  still  continue  to  functionate,  but  in 
tuberculosis,  suppurative  kidneys,  and  maUgnant  disease,  although 
it  often  has  been,  and  still  is  being  attempted,  the  results  of  partial 
removal  of  the  kidney  are  naturally  not  so  good  as  in  other  con- 
ditions that  make  the  operation  necessary  or  preferable. 

It  would  be  interesting  to  know  just  how  much  kidney  tissue 
can  be  removed,  providing  that  left  behind  was  in  a  healthy  state, 
and  still  have  the  organ  functionate.  As  far  as  we  can  tell  at 
the  present  time,  the  amount  is  probably  between  one-half  and 
one-third  ordinarily.     Experiments  on   animals   would  tend   to 


NEPHRECTOMY 


307 


show  that  still  larger  proportions  can  be  removed,  and  such  opera- 
tions have  occasionally  been  reported  as  having  been  successfully 
performed  on  human  beings. 


Fig.   114. — Diagram  illustrating  method  of  resection  of  kidney  (redrawn  from  Pierre 

Duval). 


Fig.   115. — Partial  resection  of  kidney  (redrawn  from  Albarran). 

Ordinarily,  in  order  to  have  a  good  union  in  performing  par- 
tial nephrectomy,  a  wedge-shaped  or  cuneiform  piece  should  be 
removed  from  the  kidney.     When  possible  after  a  portion  of  the 


308  THE    SURGERY    OF    THE    KIDNEY 

kidney  has  been  resected,  the  remaining  parts  should  be  brought 
together  by  a  double  set  of  sutures — a  deep  and  a  superficial  one 
(fig.  114).  Cases  are  commencing  to  be  reported  in  which,  for 
an  injury  or  wound  to  the  kidney,  partial  nephrectomy  is  being 
found  to  work  successfully,  and  kidneys  or  portions  of  them 
which  would  in  the  past  have  been  removed,  are  at  the  present 
time  being  saved.  The  operations  for  removing  the  kidney  sac 
are  discussed  under  the  heading  of  the  Surgery  of  Ureters. 

One  of  the  most  difficult  problems  in  surgery  is  associated  with 
operations  on  the  kidney  when  both  kidneys  are  diseased.  With 
increased  frequency,  owing  to  the  refinements  recently  made  in 
diagnostic  procediure,  is  the  sturgeon  confronted  with  the  above 
condition.  Naturally  rules  governing  every  case  can  only  be 
formulated  with  great  difficulty.  Ttiberctilosis  being  the  most 
common  factor  which  involves  both  kidneys,  ureter  catheterization 
with  a  very  careful  estimation  of  the  permeability  of  each  kidney, 
according  to  the  method  referred  to  under  that  title  earlier  in  this 
volume,  should  be  carried  out.  In  addition,  very  great  attention 
should  be  given  to  the  general  conditions  surrounding  any  particu- 
lar case.  As  previously  stated,  tuberculosis  of  the  kidney  is  more 
and  more  being  observed  to  be  part  of  a  general  systemic  infection, 
and  the  conservative  views  as  regards  operative  procedures  and  the 
good  results  to  be  obtained  from  them  in  tuberculosis  of  the  kidney 
described  in  earlier  editions  of  this  work,  we  think  that  further 
experience  has  shown  to  be  advisable.  Except  in  rare  cases  no 
operation  should  be  performed  until  the  effects  of  open-air  life  have 
been  previously  carefully  observed. 

On  the  other  hand,  among  these  general  factors,  a  strongly 
septic  kidney,  whether  from  tuberculosis  or  any  other  factor,  may 
so  imperatively  require  removal  that  it  should  be  undertaken  even 
if  the  other  kidney  is  involved.  Apparently  the  septic  condition 
may,  in  rare  cases,  so  embarrass  the  better  kidney  that  the  removal 
of  the  diseased  one  may  improve  the  functioning  of  the  remaining 
one.  It  is  in  cases  like  this  that  a  great  difficulty  arises,  because 
the  results  given  by  the  tests  for  kidney  permeability,  as  can  natu- 
rally be  seen  under  such  conditions,  are  not  infallible. 

Concerning  operations  on  a  kidney  where  the  other  kidney  is 
involved,  due  to  stone  in  the  kidney  or  kidneys,  a  different  condi- 


ISnePHRECTOMY  309 

tion  of  afiFairs  exists.  Here  the  tests  for  kidney  permeability  are  of 
very  great  value  in  showing  whether  the  other  kidney  will  be  able 
to  do  the  work.  In  other  words,  a  condition  may  exist  of  two  plus 
factors,  one  in  each  kidney,  which  combined  will  be  enough  to 
carry  out  the  work  of  the  system,  in  which  case  nephrectomy  should 
not  be  performed,  but  every  attempt  made  to  preserve  as  much  as 
possible  the  integrity  of  the  remaining  kidney  tissue  in  each  kid- 
ney. In  cases  of  doubt  generally  an  exploratory  operation  can  be 
made,  and  each  kidney  palpated  and  carefully  observed  with  no 
detrimental  results  in  such  cases  unless  inflammatory  conditions 
exist  in  the  kidney.  Operating  through  Edebohls'  incision  is 
recommended.  In  cases  of  tumor  of  the  kidney  the  same  general 
rules  apply  as  for  stone  in  the  kidney.  A  very  careful  examination 
should  be  previously  made  of  the  functioning  power  of  the  remain- 
ing kidney.  Here  the  character  of  the  tumor  itself  has  a  bearing 
on  the  subject  as  to  whether  it  is  malignant  or  benign.  Two  tumors 
of  apparently  benign  character,  one  in  each  kidney,  which  show  no 
indication  of  becoming  malignant  or  giving  rise  to  detrimental 
effect  on  the  general  condition,  should  probably  be  allowed  to 
remain  without  operation,  the  individual  being  kept  from  time  to 
time  under  observation.  A  case  of  this  description  has  been  ob- 
served by  one  of  us  for  many  years.  The  reader  is  referred  in  this 
connection  to  the  other  articles  concerning  tumors  of  the  kidney 
and  their  diagnoses. 

Remarks  on  Nephrectomy.^ — There  is,  at  the  present  time,  no 
one  incision  that  may  be  considered  as  undeniably  the  best  for 
the  purpose  of  cutting  into  or  removing  the  kidney.  The  choice 
of  the  incision  to  be  used  must  depend  largely  on  the  particular 
case  in  hand  and  on  the  personal  equation  and  preference  of  the 
operator.  The  somewhat  brief  description  of  the  various  opera- 
tions on  the  kidney  that  has  been  given  has  reference  to  them  as 
they  are  ordinarily  performed.  The  surgeon  familiar  with  abdom- 
inal work  will  be  more  likely  to  operate  on  the  kidney  through  the 
abdominal  route  than  one  unaccustomed  to  it.  This  method  is 
particularly  valuable  in  those  cases  in  which  a  large  kidney  is  to  be 
removed,  an  extensive  renal  tumor  excised,  or  when  it  is  found 
desirable  to  examine  the  appendix  or  other  abdominal  organs  at 


3IO  THE  SURGERY  OF   THE  KIDNEY 

the  same  time.  If  the  kickiey  is  small  and  the  space  between  the 
border  of  the  twelfth  rib  and  the  crest  of  the  ilium  is  wide,  Kde- 
bohls'  incision  will  permit  examination  of  the  kidney  and  probably 
serve  for  its  removal. 

For  general  purposes,  the  Israel  incision,  as  illustrated  (fig.  97), 
will  be  found  satisfactory.  This  incision  begins  just  below  the  bor- 
der of  the  twelfth  rib,  about  3^  inches  from  the  spine,  runs  down- 
ward and  outward  to  a  point  about  an  inch  above  the  pelvic  rim, 
and  then  runs  forward,  keeping  parallel  with  the  rim  of  the  pelvis 
and  about  an  inch  above  it.  The  incision  should  cut  deeply  through 
the  muscles  of  the  back  until  the  cavity  in  which  the  kidney  Ues 
is  reached ;  it  should  then  be  carried  onward  slowly  and  carefully, 
deep  retractors  being  used,  until  it  is  large  enough  to  permit  re- 
moval of  the  organ.  Ordinarily,  the  peritoneum  will  be  encoun- 
tered at  the  junction  of  the  incision  with  the  anterior  axillary 
border.  At  this  point,  if  it  is  desired  to  carry  the  incision  further, 
the  peritoneum  may  be  pushed  ahead  in  front  of  the  incision, 
without  being  opened.  The  same  course  is  followed  if  the  long 
transverse  incision  is  selected.  This  incision  is  useful  also  in  re- 
moving a  large  kidney  or  one  to  which  a  large  growth  is  attached. 
Ordinarily,  in  performing  nephrotomy  or  nephrectomy,  the  old- 
fashioned  loin  incision,  as  illustrated  in  fig.  loi,  is  a  serviceable 
one.  If  the  Edebohls  incision  is  selected  in  any  given  operation 
and  it  is  found  to  be  too  small,  the  outer  margin  of  the  quadratus 
lumborum  may  be  nicked  near  its  insertion  into  the  crest  of  the 
iUum,  as  suggested  by  Edebohls.  This  method  is  especially 
valuable  when  an  examination  of  the  appendix  or  other  organs  is 
to  be  made,  with  a  view  to  removal. 

In  operating  for  removal  of  the  kidney,  the  chief  danger  lies  in 
hemorrhage,  which  is  not  ordinarily  of  the  arterial  type,  but  comes 
from  the  veins  or  from  the  small  vessels  of  the  incised  kidney. 
Care  should  be  used  not  to  commence  the  incision  too  near  the 
spine,  the  wounding  of  an  intercostal  artery  giving  rise  to  profuse 
hemorrhage. 

Not  infrequently,  however,  hemorrhage  may  seem  more  severe 
than  it  really  is,  due  to  the  fact  that  the  cavity  takes  on 
an  exaggerated  size,  so  that  slight  oozing  may  give  the  im- 
pression  of   serious   loss   of   blood.     In   such   cases  it  is  aston- 


NEPHRECTOMY  3 11 

ishing  to  observe  how  quickly  bleeding  will  cease  when  sUght 
pressure  is  made  with  gauze  over  the  wounded  surface  of  the 
kidney;  this,  followed  by  careful  sponging  to  remove  the  col- 
lection of  blood  in  the  cavity,  wiU  leave  a  comparatively  dry 
operative  field.  If  much  difficulty  is  experienced  in  tying  off  the 
ureter,  the  forceps  may  be  allowed  to  remain  in  the  woimd  for  a 
few  hours  after  the  kidney  has  been  removed.  It  seems  hardly 
necessary  to  mention  that  a  sufficient  number  of  Ugatures  should 
be  placed  around  the  ureter  and  the  adjacent  blood-vessels  to 
obviate  secondary  hemorrhage,  and  that  after  the  kidney  has 
been  removed,  no  attempt  should  be  made  to  close  the  wound 
unless  it  has  been  definitely  ascertained  that  all  bleeding  has  been 
checked. 

Sometimes  the  pleura  descends  lower  in  the  back  than  usual  and 
may  be  wounded.  If  this  accident  occurs,  it  should  be  immediately 
sutured  and  care  taken  that  the  patient  is  kept  on  his  back  for 
several  days. 

The  peritoneum  is  occasionally  incised  through  inadvertence. 
The  incision  should  be  immediately  reunited  with  fine  catgut. 

The  fatty  capsule  when  met  with  should  preferably  be  incised 
a  few  inches  on  a  director,  as  the  finger  can  be  more  easily  intro- 
duced than  if  it  is  torn  through.  After  the  finger  is  introduced 
it  should  be  swept  around  over  the  surface  of  the  kidney,  patiently 
freeing  the  organ  from  the  adhesions  between  its  surface  and  the 
fatty  capsule;  then  when  it  is  well  freed,  if  the  fist  of  the  assistant 
makes  firm  counterpressure  over  the  abdominal  waU,  it  will  aid 
materially  in  dehvering  the  kidney  through  the  opening  if  the  loin 
incision  has  been  employed.  Sometimes  the  fatty  capsule  and 
true  capsule  are  almost  grown  together.  In  operating  on  a  pus 
kidney,  if  the  abscess  in  the  kidney  is  localized,  it  is  as  well  to  re- 
move as  httle  of  the  fatty  capsule  as  may  be  required  to  properly 
locate  and  drain  the  abscess,  so  as  to  prevent  infiltration  as  much 
as  possible  into  the  surrounding  tissues.  It  is  easy  to  isolate  the 
ureter  from  the  web-like  tissue  that  surrounds  the  ureter  and 
blood-vessels  if  it  is  remembered  that  in  the  loin  incision  the  ureter 
is  toward  the  lower  end  of  the  incision. 

Under  ordinary  circumstances,  after  the  removal  of  a  kidney  in 
which  no  pus  is  found,  the  wound  may  be  closed  inunediately 


312  THE   SURGERY   OF   THE   KIDNEY 

with  three  sets  of  sutures,  two  going  through  the  muscles  and  one 
through  the  skin.  In  performing  nephrectomy  in  the  presence  of 
an  abscess  cavity  either  in  the  kidney  or  in  its  immediate  neigh- 
borhood, a  drainage-tube  should  be  inserted  following  the  opera- 
tion, and  the  cavity  treated  as  in  the  case  of  a  pus-cavity  existing 
elsewhere  in  the  body. 

In  the  removal  of  a  kidney,  besides  the  difficulties  that  occur 
because  of  the  size  of  the  organ  and  the  presence  of  adhesions,  in 
very  rare  cases  of  renal  or  perirenal  abscess  the  kidney  itself  is  hard 
to  find,  and  sometimes,  strange  as  it  may  seem,  it  cannot  be  dis- 
covered at  all,  having  been  so  extensively  destroyed  as  practically 
to  have  disappeared.  In  these  cases,  if  a  drainage-tube  has  been 
inserted,  all  goes  well  while  the  tube  is  in  position,  but  after  its 
removal  recurrent  abscesses  or  cysts  are  likely  to  form.  In  such  pa- 
tients the  use  of  a  permanent  drainage-tube  in  the  loin  is  indicated ; 
this  tube,  while  it  may  cause  considerable  inconvenience,  will  not 
necessitate  confining  the  patient  to  bed,  nor  will  it  hinder  him 
from  performing  his  customary  duties.  Suppurating  kidneys 
that  it  is  found  difficult  to  remove  at  first  may,  after  the  pus- 
cavity  has  been  drained,  be  removed  at  a  second  operation  with 
more  ease. 

In  removing  the  kidney  it  is  advisable,  under  ordinary  circum- 
stances, to  tie  off  the  blood-vessels  as  the  operation  progresses, 
instead  of,  as  is  often  the  custom  in  similar  operations,  to  allow 
the  artery  forceps  to  remain  on  any  bleeding  vessels  until  after 
the  operation  is  nearly  completed.  The  operator  will  then  not 
have  the  forceps  in  his  way,  as  might  otherwise  prove  the  case. 
Care  should  be  used  in  making  the  slight  incision  through  the  fatty 
capsule  before  stripping  it  off  from  the  capsule  proper  to  avoid,  if 
possible,  nicking  the  kidney  surface.  In  dealing  with  a  pus  kidney 
or  a  sac  kidney  the  wall  is  apt  to  be  very  thin  between  the  cavity 
and  the  capsule  of  the  kidney,  and,  therefore,  easily  punctured.  It 
is  unwise  to  flood  the  field  of  operation  with  pus  or  other  contents 
of  the  sac  if  it  can  be  avoided.  It  very  rarely  happens,  but  it  may 
occur,  through  the  size  of  a  tumor,  through  adhesions,  or  through 
some  malposition,  that  it  is  almost  impossible  to  reach  the  ureter 
and  its  accompanying  blood-vessels  so  as  to  tie  off  the  pedicle  of 
the  kidney.      In  such  a  case  either  pole  of  the  kidney  may  be 


NEPHRECTOMY  313 

decapitated  and  large  forceps  put  across  the  stump  so  as  to  arrest 
the  hemorrhage.  This  having  been  done,  the  pedicle  of  the  kid- 
ney can  then  be  reached  and  tied  off.  The  kidney  will  then  only 
be  attached  by  the  remaining  pole,  and  can  be  easily  removed. 
The  question  of  renal  or  perirenal  fistula  and  their  prevention 
and  treatment  has  been  well  discussed  by  Albarran  in  his  recent 
work.  A  frequent  cause  of  fistula  is  the  imperfect  breaking 
down  of  pus  cavities  which  may  exist  at  the  time  of  an  operation 
on  a  pus  kidney,  or  for  the  removal  of  stone  from  an  infected  kid- 
ney. Naturally,  relief  follows  another  operation  if  the  pus  pock- 
ets are  so  broken  down  and  proper  drainage  can  take  place.  Or, 
if  any  pus  pocket  can  be  found  around  the  kidney,  drainage  of 
such  a  cavity  will  effect  a  cure.  Sometimes  curettage  of  the 
tissues  surrounding  the  kidney  will  be  found  effective.  If  the 
fistula  secretes  urine  as  well  as  pus  the  permeability  of  the  ureter 
should  be  looked  into,  and  the  effect,  if  possible,  of  the  ureter 
retention  catheter  tried  for  several  days  before  operating.  A 
simple  urinary  fistula  may  be  cured  by  such  measures,  or  a  ureter 
retention  catheter  used  following  a  nephrotomy  and  allowed  to 
remain  a  few  days  after  the  drainage-tube  through  the  loin  has 
been  removed,  may  prove  of  valuable  service.  Unfortunately, 
the  experience  of  most  operators  in  this  country  does  not  bear 
out  their  European  colleagues,  either  as  regards  the  ease  with 
which  the  ureter  catheter  can  be  introduced,  or  its  size,  or  the 
duration  of  time  which  it  can  be  retained  without  becoming  in- 
crusted.  Nephrectomy  by  morcellement  is  the  name  applied  to 
this  operation.  In  performing  this,  as  in  all  operations  on  the  kid- 
ney, great  care  should  be  used  in  the  selection  of  the  clamps. 
Those  used  should  lock  firmly,  when  no  space  should  exist  between 
the  blades.  Clamps  which  tear  through  the  structures  should  not 
be  used.  Right-angled  clamps  will  sometimes  be  found  of  use  in 
performing  nephrectomy.  In  partial  or  complete  nephrectomy, 
at  least  a  quarter  of  an  inch  of  tissue  should  be  left  on  the  outer 
side  of  the  clamp,  so  that  the  pedicle  or  any  portion  of  the  kid- 
ney held  by  the  clamp  may  not  slip  out  from  under  it  when  the 
kidney  is  removed.  We  consider  this  advice  important,  as 
failure  to  carry  out  this  detail  in  an  operation  performed  by  one 
of  us  was  responsible  for  the  severed  pedicles  slipping  from  under 


314  THE   SURGERY  OF   THE    KIDNEY 

the  clamp.  When  this  unfortunate  accident  occurs,  immediate 
attempts  should  be  made,  through  the  means  of  long  forceps,  to 
catch  the  bleeding  vessels  at  the  bottom  of  the  cavity.  This 
done,  difficulty  may  be  experienced  in  ligating  them  beyond  the 
end  of  the  clamp  at  the  bottom  of  the  cavity,  but  a  series  of 
Ugatures  surrounding  the  clamp  into  the  surrounding  tissues, 
each  put  a  little  lower  than  the  other,  will  make  it  possible  to 
eventually  ligate  the  vessel  beyond  the  end  of  the  clamp.  Fol- 
lowing nephrectomy,  the  cavity  should  be  carefully  examined 
with  a  portable  electric  Ught  to  see  that  no  bleeding  points 
remain  or  tear  in  the  peritoneum  exists. 

In  removal  of  tumor  of  the  kidney  the  operator  should  be 
guided  to  a  great  extent  by  the  conditions  present  in  any  given 
case,  and  whether  nephrotomy,  nephrectomy,  partial  or  complete, 
or  nephrectomy  with  ablation  of  the  ureter  as  completely  as  pos- 
sible, should  be  done  will  depend  upon  the  circumstances  sturound- 
ing  any  given  case,  such  as  the  nature  of  the  tumor,  its  get-at- 
ability,  and  the  condition  of  the  other  kidney. 

Cysts  of  the  kidney,  when  due  to  such  conditions  as  hydatids, 
should  be  removed  entire  without  being  opened,  the  kidney  sewed 
up,  and  preserved.  In  mahgnant  tumors  or  tubercular  growths 
nephrectomy  should  be  performed.  Albarran  states  that  when  he 
operates  on  both  kidneys  he  always  operates  on  the  best  one  first 
in  order  that  he  may  know  and  have  some  idea  as  to  how  much 
healthy  kidney  tissue  there  is  in  the  body.  Many  surgeons  prefer 
the  abdominal  route  for  the  excision  of  large  tumors.  It  is 
astonishing  what  Httle  difference  there  is  in  the  death-rate  between 
the  abdominal  route  and  the  extraperitoneal  route,  as  shown  by 
statistics  in  nephrectomy.  It  is  recommended  in  operating  for 
mahgnant  tumors  that  care  should  be  used  to  remove  the  supra- 
renal capsule  and  gangha  as  much  as  possible ;  this  appUes  only  to 
one-sided  growths. 

Nephrectomy  should  be  performed  for  tumors  of  the  pelvis  of 
the  kidney.  These  tumors  are  comparatively  rare,  and  are  most 
often  papillomata.  When  possible,  it  has  been  recommended,  in 
such  cases,  to  remove  the  ureter  completely,  as  papilloma  of  ureter 
is  apt  to  be  present.  Tumors  of  the  capsule  of  the  kidney,  under 
ordinary  circumstances,  if   benign,  should  be  removed   without 


DECAPSULATION  OF   THE  KIDNEY 


315 


removal  of  the  kidney.  Nephrectomy  is  the  operation  for  timiors 
of  the  kidney  in  children,  which  are  almost  invariably  malignant, 
and  generally,  even  after  successful  removal,  recur.  In  some 
cases  microscopic  examination  of  the  tumor  at  the  time  of  oper- 
ation may  aid,  but  it  is  apt  to  be  unsatisfactory. 

Mayo,  of  Rochester,  has  invented  a  table,  or  an  appropriate 
top  for  a  table,  on  which  to  perform  operations  on  the  kidney,  of 
which  there  is  an  illustration  in  this  work  (see  fig.  99) , 

DECAPSULATION  OF  THE  KIDNEY 
This  procedure  has  already  been  spoken  of  in  connection  with 
the  operation  for  nephropexy.     The  kidney  having  been  reached 


.1 


••iSl- 


Fig.  116. — Decapsulation  of  the  true  capsule  of  the  kidney  (redrawn  from  Albarran). 

through  Edebohl's  incision,  or  through  the  ordinary  loin  inci- 
sion, the  fatty  capsule  having  been  removed,  the  true  capsule  of 
the  kidney  is  incised  on  a  director  and  the  capsules  shelled  back 
to  as  great  an  extent  as  desired,  and  what  may  be  considered 
necessary  removed,  care  being  taken  not  to  injure  the  paren- 
chyma of  the  kidney.     The  amount  of  hemorrhage  is  generally 


3i6  the;  surgery  of  the  kidney 

slight  and  easily  controlled.  Cicatricial  tissue  in  a  short  time 
forms  over  the  decapsulated  area.  The  operation  has  sometimes 
been  repeated  several  times  on  the  same  individual,  the  new 
capsule  made  up  of  the  cicatricial  tissue  itself  being  removed. 
The  usefulness  of  this  operation  alone  in  the  treatment  of  Bright's 
disease  has  in  the  past  by  some  operators  been  overestimated. 
The  decapsulation  in  whole  or  in  part  is  in  some  conditions  a  com- 
ponent part  of  other  operations  on  the  kidney. 

SURGICAL  TREATMENT  OF  BRIGHT'S  DISEASE 
The  treatment  of  interstitial  nephritis  and  pyelonephritis  by 
means  of  continuous  catheterization-  of  the  bladder  has  been  advo- 
caxp'^  "  ^  means  to 
seen  method 
is  re\  -itis  in 
the  al  nd  but 
little  1  X  at  its 
neck.  1  believe 
they  ^  ^e  as  to 
just  th\  Vj  a  pro- 
cedure n  state  or 
other  cone  e  or  in- 
advisable. \  ;r  in  the 
volume  undei  ,y  we  have 
met  with  a  dab  lave  never 
had  treatment  foi  ladder  who 
give  a  history  of  havi.  ending  over 
a  considerable  period  of  tu.  ,u  catheteriza- 
tion to  have  an  immense  amount  v.. ^^l  urine  in  the  bladder; 

in  some  of  our  cases  as  much  as  2  quarts.  In  these  individuals 
the  amount  of  residual  urine  bears  very  Httle  relation  to  the  ob- 
struction to  urination,  although  some  enlargement  of  the  prostate 
generally  exists.  They  have  an  interstitial  nephritis  and  prob- 
ably some  hydro-  or  pyonephrosis  which  may  not  be  marked. 
The  interstitial  nephritis  may  be  a  httle  hard   to  diagnose,  al- 

^  "On  the  Treatment  of  Interstitial  Nephritis  and  Pyelonephritis  by  Con- 
tinuous Catheterization  of  the  Bladder,"  "  Boston  Medical  and  Surgical  Jour- 
nal," 1904. 


SURGICAL    TREATMENT   OI^   BRIGHT'S   DISEASE  317 

though  the  urinary  solids  will  generally  be  found  to  be  somewhat 
diminished,  but  the  patients  themselves  seem  to  be  suffering  from 
a  general  intoxication  due  to  the  absorption  of  urinary  products, 
and  have  such  symptoms  as  indigestion,  coated  tongue,  and  a 
marked  urinous  odor  is  apt  to  pervade  all  their  surroundings. 
This  is  the  type  benefited  by  the  continuous  catheterization. 

Many  surgeons  have  for  some  time  past  been  advocating  the 
operative  treatment  of  Bright's  disease,  but  the  results  of  these 
operations  thus  far  have  not,  in  our  opinion,  been  attended  with 
the  desired  success.  By  their  efforts,  however,  the  subject  of 
kidney  surgery  has  been  broadened,  and  they  have,  in  addi- 
tion, improved  the  operative  technic  and  given  a  clearer  concep- 
tion as  to  the  extent  of  surgical  interference  that  will  be  tolerated 
by  the  kidney. 

It  has  long  been  known  that  in  certain  cases  of  persistent 
renal  hemorrhage  relief  will  follow  an  incision  into  the  kidney. 
This  is  probably  due  to  the  fact  that  tension  is  thus  relieved, 
and  that  the  formation  of  cicatricial  tissue,  which  apparently 
follows  decapsulation,  does  not  take  place  after  incision.  The 
operation  is,  therefore,  to  be  recommened  in  certain  cases  of 
nephritis  attended  with  hemorrhage.  For  suspected  nephritis 
with  persistent  pain  in  and  around  the  region  of,  the  kidney,  it 
ma}^  be  advisable  to  make  an  exploratory  operation.  If  no  excit- 
ing cause  is  found  outside  the  kidney,  splitting  of  the  capsule  of 
the  organ  should  ordinarily  cause  but  slight  damage,  and  may 
give  an  insight  into  the  true  state  of  the  kidney.  In  some  cases 
this  procedure  may  give  diagnostic  aid;  it  should  not  be  per- 
formed too  frequentty,  but  reser^^ed  for  those  cases  in  which  the 
most  exhaustive  general  measures  have  failed  to  lead  to  a  correct 
diagnosis,  and  in  which  careful,  painstaking,  and  prolonged  treat- 
ment by  nonsurgical  methods  has  given  no  relief  from  hemor- 
rhage or  pain.  Opening  and  draining  the  pelvis  of  the  kidney 
for  anuria  due  to  the  presence  of  renal  calculi  or  when  symptom- 
atic, as  from  pregnancy,  may  save  or  prolong  the  life  of  the  indi- 
vidual, and  in  some  rare  cases  of  partial  anuria  may  be  the  last 
means  of  overcoming  uremic  intoxication  which  is  progressively 
growing  more  marked,  and  for  which  no  other  measures  have 
been  able  to  afford  reUef. 


3l8  THE   SURGERY   OE   THE   KIDNEY 

It  is  to  be  hoped  that  in  the  near  future  clearer  views  will  be 
had  as  to  the  proper  procedures  to  adopt  in  the  surgical  treatment 
of  Bright's  disease  than  at  present  exist.  One  reason  why  the 
statistics  on  the  operative  results  of  the  past  are  of  so  little  value 
is  that  the  diagnosis  of  the  disease  and  the  amoiuit  of  improve- 
ment following  the  operation  have  been  based  on  the  results  of 
urinary  examinations,  which  have  been  shown  to  be  often 
misleading. 

While  our  experience  has  not  been  such  as  to  convince  us  of 
the  great  benefit  to  be  derived  from  the  operative  procedures 
advocated  for  the  cure  of  Bright's  disease  itself,  it  has  been  such 
as  to  lead  us  to  believe  that,  through  increased  ability  on  the  part 
of  the  profession  to  diagnose  diseases  of  the  kidneys,  there  will 
be  a  corresponding  increase  in  the  number  of  diseased  conditions 
found  that  will  be  amenable  to  surgical  treatment. 

LAVAGE  OF  THE  PELVIS  OF  THE  KIDNEY 
Lavage  of  the  pelvis  of  the  kidney  through  the  ureteral  catheter 
is  so  easily  carried  out,  once  the  physician  becomes  familiar  with 
iu"eteral  catheterization,  that  the  method  is  now  being  frequently 
employed  for  the  reUef  of  pyelonephritis  and  its  allied  conditions. 
The  solutions  generally  employed  are  silver  nitrate,  not  stronger 
than  1 :  10,000,  boric  acid,  argyrol,  protargol,  or  albargin.  Ordi- 
narily, the  irrigations  should  not  be  made  oftener  than  once  a 
week.  The  ureteral  catheter  having  been  introduced,  the  con- 
tents of  a  small  syringe,  containing  from  i  to  4  ounces  of  the  solu- 
tion, are  very  slowly  injected  through  the  outer  end  of  the  cathe- 
ter, the  syringe  is  removed,  and  the  injected  fluid  is  allowed  to 
flow  out  through  the  catheter.  The  catheter  is  then  removed,  or 
a  small  amount  of  fluid  may  be  injected  as  the  catheter  is  removed 
with  the  object  of  distending  the  pelvis  of  the  kidney  and  the 
ureter.  If  too  much  or  too  strong  a  solution  is  used,  renal  colic 
may  ensue;  the  procedure  is  often  followed  by  a  sensation  of 
fulness  in  the  kidney.  Albarran  is  a  warm  advocate  of  the 
usefulness  of  irrigations  of  the  pelvis  in  pyonephritis  through 
a  retention  catheter  for  several  days  before  an  operation,  as  he 
thinks  by  disinfecting  the  pelvis  of  the  kidney  better  after  opera- 
tive results  than  would  otherwise  occur  will  ensue. 


LAVAGK  OF  THE  PEI^VIS   OF  THE   KIDNEY  319 

Judging  from  the  carefully  recorded  histories  of  the  cases  of 
Casper  and  Richter,  the  results  following  the  use  of  this  method 
are  not  such  as  to  encourage  the  beUef  that  practical  benefit  will 
accrue  in  any  large  nmnber  of  cases.  In  certain  cases  it  appar- 
ently tends  to  hasten  the  disappearance  of  pus  in  the  urine  in  cases 
of  pyelitis. 

The  chief  dif&culty  that  confronts  us  in  estimating  the  true 
value  of  the  aforesaid  procedure  in  the  treatment  of  pyelonephritis 
is  that  a  correct  diagnosis  is  not  always  possible,  some  observers 
considering  pyuria  to  be  present  when  only  a  few  leukocytes  are 
found  in  the  urine.  Repeated  investigations  will  be  necessary  before 
a  correct  estimation  of  the  benefits  to  be  derived  from  this  pro- 
cedure can  be  safely  made;  the  writers  beUeve  that  it  has  but  a 
limited  range  of  usefulness. 


CHAPTER  XVII 

ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGIC  ANATOMY 
OF  THE  URETER 

ANATOMY  AND  PHYSIOLOGY  OF  THE  URETER 

The  ureters  are  hollow  tubes,  from  fourteen  to  sixteen  inches 
in  length,  that  conduct  the  urine  from  the  kidneys  to  the  bladder. 
Embryologically,  as  anatomically,  they  are  direct  continuations 
of  the  pelvis  of  the  kidney  and  they  are  formed  from  an  offshoot 
of  the  Wolffian  duct.  They  lie  behind  the  peritoneum,  and  enter 
the  bladder  at  its  base  in  an  oblique  direction,  in  such  a  manner 
than  when  the  bladder  is  distended,  the  resulting  pressure  auto- 
matically closes  the  ureteral  orifice.  They  are  made  up  of  an 
inner  mucous  membrane  of  transitional  epithelium,  laid  down 
upon  a  delicate  supporting  tissue,  external  to  which  is  found  a 
coat  of  smooth  muscle,  consisting  of  an  internal  longitudinal 
and  an  external  circular  layer.  This  is  invested  by  a  fibrous 
connective-tissue  sheath  in  which  circular  elastic  fibrils  are  plenti- 
ful. Normally,  the  walls  of  the  ureter  are  collapsed  and  in  contact. 
Cross-sections  show  the  collapsed  lumen  thrown  into  longitudinal 
folds  giving  a  stellate  outline.  The  normal  distended  lumen 
measures  but  from  two  to  four  millimeters  in  diameter.  Under 
numerous  conditions,  as  in  hydronephrosis  or  pyonephrosis, 
however,  it  may  become  considerably  dilated,  and  may  even  per- 
mit the  passage  of  a  stone  2  cm.  or  more  in  diameter.  As  a 
rule,  however,  stones  of  this  size  are  almost  certain  to  lodge  in 
the  renal  pelvis,  or  if  they  enter  the  ureter,  at  the  entrance  to 
the  bladder. 

The  propulsion  of  the  urine  through  the  ureter  is  not  a  simple 
matter  of  gravity,  but  takes  place  as  a  result  of  peristaltic  waves, 
originating  in  the  pelvis  of  the  kidney  and  passing  downward. 
These  contractions  occur  every  few  seconds  and  force  the  urine 
before  them  by  a  series  of  rhythmic  spurts.     This  peristaltic  mus- 

320 


PATHOLOGIC  ANATOMY  OP  THE;  URKTERS         321 

cular  action  accounts  in  large  measure  for  the  facility  with  which 
masses  of  necrotic  tissue  or  calculi  are  forced  through  the  lumen 
of  the  ureters. 

The  ureter  receives  its  nerve-supply  from  the  inferior  mesenteric, 
spermatic,  and  hypogastric  plexuses.  Its  contractions  are,  how- 
ever, probably  due  largely  to  automatic  muscular  movements. 

PATHOLOGIC  ANATOMY  OF  THE  URETERS 

Malfonnations  of  the  ureters  are  by  no  means  uncommon,  one 
of  the  most  frequent  of  these  being  an  unusual  point  of  entrance 
into  the  bladder.  At  times  both  ureters  discharge  through  the 
same  papilla,  or  occasionally  only  one  ureter  exists,  associated 
perhaps  with  horseshoe  kidney  or  some  other  renal  abnormality. 
These  variations  should  constantly  be  borne  in  mind  in  perform- 
ing cystoscopic  examination. 

Most  of  the  pathologic  changes  of  the  ureter  are  practically 
identical  with  those  of  the  renal  pelvis  or  bladder.  It  is  there- 
fore chiefly  concerned  with  various  inflammatory  diseases,  and 
with  the  results  of  and  the  passage  of  urinary  calculi. 

Tumors  of  the  ureters  are  papillomatous,  cystic,  or  carcinoma- 
tous in  type.  They  are  almost  invariably  associated  with,  or  a 
part  of,  growths  in  one  of  the  adjacent  organs,  especially  in  the 
bladder  or  kidney.  Primary  growths  of  the  ureter  have  been 
reported,  but  are  so  rare  as  to  be  regarded  in  the  light  of  surgical 
curiosities.  In  the  writers'  experience  but  a  single  primary  tumor 
of  the  ureter  has  been  found — that  an  epithelioma  situated  near 
penetration  of  the  bladder-wall. 

Cysts  of  the  ureter  are  occasionally  reported;  two  such  cases 
were  presented  before  the  New  York  Pathological  Society  during 
1907  (Bond  Stow,  Otto  Schultze),  and  a  considerable  series  of 
these  cases  has  been  collected  by  Harris.^  They  are  of  relatively 
small  clinical  importance ,  though  most  interesting  from  the  pathol- 
ogist's standpoint.     They  are  probably  inflammatory  in  origin. 

Inflammation.^ — The  ureters  are  histologically  a  continuation  of 

the  bladder  structures  and,  to  a  considerable  extent,  of  that  of  the 

urethra;  hence  when  subject  to  irritation,  similar  conditions  as 

occur  in  the  bladder  and  urethra  will  naturally  ensue  after  infection 

'  "American  Medicine,"  vol.  iii,  p.  731. 


322        ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY    OF    URETER 

or  irritation  from  any  cause.  Obstruction  of  the  mouth  of  the 
ureteral  glands  gives  rise  to  an  exudative  inflammation  with 
ulceration  or  cyst  formation,  the  ureters  showing  a  particularly 
strong  tendency  toward  the  development  of  these  cysts.  As  a 
final  result  of  acute  inflammatory  processes  there  is  a  predisposi- 
tion to  the  formation  of  scar  tissue,  resulting  in  stricture;  never- 
theless, in  studying  the  literature  on  the  subject  of  diseases  of  the 
ureters  it  is  somewhat  astonishing  to  observe  with  how  little 
frequency  strictures  of  the  ureter  have  been  reported.  As  the 
result  of  the  writers'  observations,  moreover,  they  believe  that 
stricture  of  the  ureter  is  not  so  infrequent  as  is  commonly  supposed, 
and  that  the  subject  is  worthy  of  more  attention  than  it  has 
received  in  the  past.  Attempts  at  catheterization  of  the  ureters 
have  recently  resulted  in  the  finding  of  an  increased  number 
of  such  strictures.  As  illustrative  of  a  not  uncommon  class  may 
be  cited  a  case  that  recently  came  under  the  care  of  one  of  the 
writers.  On  attempting  to  catheterize  the  left  ureter,  renal 
calculi  being  suspected,  although  the  mouth  of  the  ureter  could 
be  made  out  and  there  was  *  apparently  no  other  obstruction, 
still  it  was  found  impossible  to  pass  a  very  small  catheter — the 
smallest  available — because  of  contraction  of  the  mouth  of  the 
ureter.  No  history  or  clinical  sign  indicative  of  ureteral  stricture 
was  manifest. 

Stone. — A  stone  in  the  kidney,  as  it  works  its  way  down  into 
the  ureter,  gives  rise  to  intense  pain  of  a  stabbing  or  burning  char- 
acter. This  pain  begins  in  the  back,  extends  around  to  the  side 
and  down  the  groin,  in  a  manner  characteristic  of  almost  all  forms 
of  renal  colic.  Not  very  infrequently  a  stone  lodging  in  the  ure- 
ter will  cause  a  distention  of  the  tube  and  set  up  hydronephrosis. 
These  cases  are  generally  differentiated  easily  from  diseased 
conditions  of  the  cecum  or  appendix,  by  the  usual  clinical  signs^ 
and  examination  of  the  urine  either  with  or  without  cystoscopy 
is  a  method  of  great  assistance. 

The  ureters  occasionally  suffer  from  traumatism,  although  they 
are  so  well  protected  and  are  placed  so  deeply  that  injuries  are 
comparatively  rare.  A  few  cases  have  been  reported  as  the  result 
of  knife  and  shot  wounds. 

The  ureter  is  frequently  diseased  as  the  result  of  downward 


PLATE  IX 


LEFT 
SIDE 


RIGHT 
SIDE 


INNER   LEFT 

URETER  OPENING 


OUTER    LEFT       v 
URETER  OPENING     '^ 


/ 


RIGHT  URETER 
OPENING 


Dr.  Eransford  Lewis's  case  of  three  ureters,  demonstrated  during  life  by  ureter 
catheterization  and  radiograph.  Gonorrheal  infection  of  one  of  the  three  ureters. 
Permanently  relieved  by  ureteral  lavage. 


PATHOLOGIC   ANATOMY    OF    THE    URETERS 


323 


extension  of  a  lesion  of  the  renal  pelvis,  or  it  may  suffer  from  in- 
vasion by  way  of  the  bladder.  In  some  severe  types  of  urethral 
stricture  with  retention  of  urine  dilation  of  the  ureters  occurs. 
Fig.  117  illustrates  such  a  condition.  This  principle  is  applied  in 
the  treatment  of  calculi  retained  in  the  ureter,  and  it  has  been 
suggested  that  the  bladder  be  distended  with  some  warm  fluid; 


Fig.  117. — Showing  dilation  of  the  ureters  and  pelvis,  with  excavation  of  the  pyra- 
mids, caused  by  long-standing  stricture  of  the  membranous  urethra  (one-third  natural 
size)  (specimen  from  the  Museum  of  Carnegie  Laboratory). 


the  walls  of  the  ureters   might  thus  be   increased   in    diameter, 
permitting  the  stone  to  pass  through  more  easily. 

Tuberculosis  may  attack  the  ureter  as  the  result  of  the  exten- 
sion downward  of  tuberculous  disease  of  the  kidney,  or  by 
an  upward  extension  from   a  similarly  diseased   bladder.     The 


324        ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY    OF    URETER 

process  is  said  occasionally  to  give  rise  to  distention  of  the  ureter 
or  to  its  obliteration  by  stricture  formation. 

Much  has  been  written  about  kinks  in  the  ureters,  particu- 
larty  in  connection  with  floating  kidney.  The  so-called  Dietl's 
crisis,  described  elsewhere,  is  believed  to  be  due  to  this  cause, 
a  belief  that  is  not  fully  borne  out  by  postmortem  findings.  The 
writers  explain  the  occasional  occurrence  of  this  symptom-com- 
plex as  being  due  to  spasmodic  contraction  of  the  ureter  under 
certain  nervous  stimulation  similar  in  nature  to  Hke  spasmodic 
contractures  of  the  urethra  or  esophagus.  These  contractions 
are  beHeved  to  be  accelerated  or  inaugurated  by  any  slight  local 
lesion  that  exists  in  the  ureter.  In  some  cases  the  gravid  uterus 
may  press  so  severely  on  the  ureter  as  to  cause  obstruction  or 
even  serious  damage  to  the  tube. 

Not  infrequently  the  ureter  is  the  seat  of  stricture  or  fistula, 
the  result  of  injury  inflicted  on  the  tube  or  adjacent  tissues  during 
operation,  or  from  the  passage  of  stone.  The  fistula  due  to  injury 
of  the  ureter  following  operative  procedures  manifests  itself  by 
the  presence  of  the  perforation  either  at  the  site  of  the  original 
wound,  or  perhaps  in  some  other  structure  of  the  body  by  the 
discharge  of  urine.  Wounding  of  the  ureter  during  the  course  of 
an  operation  is  generally  made  apparent  by  the  immediate  pres- 
ence of  urine  in  the  wound.  The  ureter  is  occasionally  tied  dur- 
ing an  operation,  particularly  on  the  uterus  or  its  appendages. 
If  both  ureters  have  been  Hgated,  there  is  an  immediate  cessation 
of  the  urinary  flow.  On  attempting  to  pass  a  ureteral  catheter 
an  obstruction  will  be  encountered,  which,  together  with  the 
total  suppression  of  urine,  will  generally  disclose  the  condition. 
Fortunately,  in  such  cases,  when  the  wound  is  reopened  and  the 
ureters  are  freed,  they  will  ordinarily  resume  their  function  even 
if  the  constriction  has  existed  for  several  hours.  If  only  one  ureter 
has  been  tied,  and  the  condition  remains  unrecognized,  hydro- 
nephrosis ensues.  If  the  ureters  have  been  tied  off  but  a  little 
distance  from  the  kidney,  this  will  probably  manifest  itself  in  a 
few  days  by  the  occurrence  of  a  swelling,  owing  to  the  distention 
caused  by  the  retained  urine  in  the  kidney ;  or,  on  the  other  hand, 
there  may  be  marked  distention  of  the  ureter,  giving  rise  to  a 
tumor  that,  on  being  opened,  will  be  found  filled  with  urine. 


PATHOLOGIC  ANATOMY  OF  THE)  URETERS         325 

Wounds  of  the  ureter  discovered  or  inflicted  during  operation 
may  be  immediately  sutured,  with  or  without  the  introduction  of  a 
ureteral  catheter.  In  suturing  wounds  of  the  ureter  that  have  been 
made  for  the  removal  of  calculi,  great  care  should  be  exercised 
not  to  penetrate  the  mucosa  of  the  tube.  Fine  silk  Hgatures, 
which  may  afterward  be  buried  in  the  tissues,  or  any  very  rapidly 
absorbing  catgut,  may  be  used.  In  such  cases  it  is  well  to  leave 
a  drain  at  the  angle  of  the  wound  for  a  few  days  lest  leakage 
occur.  In  such  a  case  recently  under  the  writers'  care  a  ureteral 
catheter  was  allowed  to  remain  with  its  extremity  in  the  pelvis 
of  the  kidney  for  thirty-six  hours,  after  which  it  was  removed; 
no  further  leakage  occurred.  The  treatment  of  wounds  is  again 
referred  to  in  the  chapter  on  Surgery  of  the  Ureters. 

When  a  stone  in  the  ureter  has  become  impacted  and  makes 
no  further  progress  toward  the  bladder,  it  may  occasionally  be 
pushed  up  toward  the  kidney  and  thus  easily  reached  through  a 
lumbar  incision.  The  various  operative  procedures  for  the  relief 
of  diseased  conditions  of  the  ureters  will  be  described  further  on; 
it  remains  to  consider  here  briefly  the  methods  of  inspection  of 
the  ureters  as  an  aid  to  the  diagnosis. 

Diagnosis. — The  value  of  the  ^-ray  and  ureter  catheterization 
for  diagnostic  purposes  is  so  well  known  as  to  require  nothing  but 
mention  here.  The  x-ray  used  in  conjunction  with  a  15  per  cent, 
injection  of  argyrol  will  to  our  knowledge  show  on  the  plate  a 
kink  in  the  ureter.  Palpation  of  the  ureters  when  carefully  prac- 
tised is  occasionally  of  considerable  aid  in  diagnosis.  In  the  chap- 
ter on  Diseases  of  the  Kidney  the  valuable  aid  that  may  be  ob- 
tained from  palpation  and  massage  along  the  course  of  the  ureters 
in  the  diagnosis  of  pyuria  has  been  mentioned.  Other  things 
being  equal,  it  follows  that  a  bimanual  examination  of  the  ureters 
may  be  more  easily  made  in  a  thin  than  in  a  stout  subject.  Con- 
tinual practice,  however,  will  increase  the  skill  of  the  examiner. 

It  has  been  claimed  that,  by  the  introduction  of  a  finger  into 
the  rectum  above  the  prostate,  diseased  conditions  of  the  ureters 
can  sometimes  be  detected.  The  writers  have  never  been  able 
to  determine  to  their  satisfaction  that  a  lesion  of  the  ureter  could 
be  thus  accurately  differentiated  from  an  enlarged  and  diseased 
seminal  vesicle.     This  method  of  examination  is,  however,  recom- 


326       ANATOMY,    PHYSIOLOGY,    AND   PATHOLOGY    OF    URETER 

mended  by  some.  In  a  woman  it  may  be  possible,  with  one  hand 
on  the  abdomen  and  a  finger  in  the  anterior  vaginal  culdesac,  to  out- 
line a  swollen  ureter,  but  great  care  must  be  observed  not  to  con- 
found this  condition  with  some  diseased  state  of  the  ovary,  tube, 
appendix,  or  intestine. 

As  has  been  said,  the  two  greatest  aids  that  are  at  our  command 
in  diagnosing  diseased  conditions  of  the  ureters  are  ureter  cathe- 
terization and  the  x-tslj,  or  a  combination  of  both. 

The  rr-ray,  in  the  hands  of  one  skilled  in  its  use,  will  sometimes 
demonstrate  the  presence  of  a  stone  in  the  ureter  very  clearly. 
Some  admirable  specimens  of  this  work  have  been  made,  illus- 
trating the  passage  of  the  stone  down  the  ureter  into  the  bladder. 
The  pictures  were  taken  in  frequent  succession,  and  showed  the 
stone  in  many  positions  in  the  ureter  as  it  proceeded  on  its  journey. 
A  good  illustration  of  the  aid  to  be  obtained  from  a  combination 
of  the  two  methods  was  the  taking  of  an  x-ray  picture  of  a  sub- 
ject in  whom  a  metal  ureteral  catheter  had  been  introduced  from 
the  bladder  into  the  kidney.  The  metal  catheter  was  distinctly 
seen  in  the  picture,  and  outhned  the  course  of  the  ureter  very 
clearly.  It  is  doubtful,  however,  if  the  adoption  of  this  proce- 
dure as  a  routine  practice  for  the  determination  of  the  movability 
of  a  kidney,  as  recommended  by  some,  will  ultimately  be  of  great 
value.  Metal  catheters,  after  all,  must  be  used  with  considerable 
care  in  the  ureters  and  are  not  to  be  employed  in  all  cases,  but, 
as  has  been  mentioned  under  the  head  of  Floating  Kidney,  metal 
catheters  introduced  through  the  ureter  into  the  kidney,  followed 
by  the  taking  of  a  radiograph,  are  very  helpful  in  those  cases  in 
which  it  is  necessary  to  differentiate  between  a  floating  kidney 
and  a  new-growth. 


CHAPTER  XVIII 

SURGERY  OF  THE  URETERS  AND  FOR  THE  RELIEF 
OF  HYDRONEPHROSIS 

Much  has  been  written  in  the  text-books  on  surgery  regarding 
the  various  routes  by  which  the  ureters  may  be  reached.  For 
practical  purposes,  the  lumbar  inguinal  incision,  as  illustrated  in 
the  cut  (fig.  Ill),  will  enable  one  to  find  the  ureter  in  most  any 
portion  of  its  course.  The  incision  may  be  begun  just  below  the 
twelfth  rib,  or  further  along  toward  the  inguinal  region,  and  may 
be  prolonged  as  far  as  necessary,  the  peritoneum,  when  met  wdth, 
being  pushed  ahead  of  it.  Instead  of  making  the  very  long  inci- 
sion, as  shown  in  our  plate  for  discovering  the  kidney  and  ureter 
in  full  length,  if  it  is  desired  to  reach  the  ureter  in  its  pelvic  por- 
tion a  shorter  incision  may  be  used,  and  the  one  advised  by 
Albarran,  as  shown  in  the  illustration,  is  the  one  recommended. 
In  this  case  the  skin  and  muscles  should  be  cut  through  to  the 
peritoneum;  this  bifurcation  of  the  iliac  should  be  searched 
for  as  being  the  guide  to  the  ureter.  The  incision  should  begin 
a  finger-breadth  above  the  cervical  arch,  and  run  parallel  to  Pou- 
part's  ligament  until  it  arrives  at  the  level  of  the  anterior  superior 
spine  of  the  ilium,  and  then  go  up  vertically  on  the  abdominal 
wall  until  it  has  reached  a  distance  of  about  three  fingers'  breadth 
above  the  spine.  If  it  has  been  possible  beforehand  to  introduce 
a  ureter  catheter,  it  will  be  an  easy  matter  to  locate  the  ureter, 
otherwise  it  will  be  found  lying  in  and  just  outside  the  fold  of  the 
peritoneum.  If  it  is  desired  to  reach  the  ureter  in  some  portion 
very  near  the  bladder,  a  suprapubic  section  will  permit  of  the 
exploration  of  the  ureter  from  its  inner  surface.  Fenwick  sug- 
gested and  Albarran  recommends  that  in  certain  cases  where 
there  is  such  a  condition  as  a  large  stone  in  the  ureter  near  the 
opening  of  the  ureter  into  the  bladder,  it  can  be  reached  through 
a  perineal  incision,  an  operation  of  the  same  character  as  that  of 

327 


328  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

Albarran  for  the  removal  of  the  prostate  being  performed,  and  the 
space  back  of  the  bladder  being  well  opened  up,  it  will  be  very 
easy  to  locate  the  ureter  and  operate  upon  it  through  this  channel, 
the  size  of  the  calculus  making  it  easier  to  find.  The  use  of  the 
::c-ray,  which  has  been  previously  mentioned,  is  of  particular  value 
in   the  diagnosis   of   ureteral   calculi.     The   ureter   may   also   be 


Fig.  118. — Incision  for  reaching  extraperitoneally  the  iliac  portion  of  the  ureter  (redrawn 

from  Albarran). 

reached  through  an  abdominal  incision,  in  much  the  same  manner 
as  the  kidney  is  reached;  or  by  finding  the  posterior  wall  of  the 
bladder,  the  ureter  may  be  followed  along  its  course. 

Statistics  show  that  the  best  results  are  obtained  if  the  ureter 
can  be  reached  by  the  extraperitoneal  route.  The  increasing 
facility  with  which  ureter  catheterization  can  be  performed,  being 


SURGERY  OF  THE  URETERS  AND  RELIEE  OF  HYDRONEPHROSIS   329 

often  a  comparatively  simple  procedure,  will  aid  one  in  finding 
the  canal  if  a  ureteral  catheter  has  been  introduced  previous  to 
the  operation.     Gynecologists,  in  operating  on  ovarian  tumors, 


Fig.   iig. — Rolling  back  the  peritoneum  in  the  ihac  fossa  (redrawn  from  Albarran). 

will  undoubtedly  find  this  of  service,  since  by  its  use,  in  certain 
cases,  wounding  of  the  ureter  may  be  avoided. 

For  purposes  of  description  operations  on  the  ureter  may  be 
divided  into  three  principal  classes:  (i)  Operations  involving 
the  opening  of  the  ureter  into  the  kidney;  (2)  operations  concerned 
with  the  portion  of  the  ureter  that  opens  into  the  bladder;  (3) 
operations  for  wounds  of  the  ureter  or  for  the  removal  of  stones 
from,  or  for  the  relief  of  strictures  of,  the  ureter. 

Class  I. — The  operations  coming  in  this  class  are  most  gener- 


330  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

ally  practised  for  the  relief  of  renal  retention  of  urine.  Several 
of  the  conditions  in  which  these  operations  are  indicated  are 
shown  in  the  illustrations.  In  some  cases  the  pelvis  of  the  kid- 
ney becomes  so  greatly  distended  as  the  result  of  hydronephrosis 
that  almost  the  entire  length  of    the  ureter  has   to   be  resected 


Fig.  I20. — Showing  the  ureter  in  the  right  iUac  region:  i,  Common  iliac  artery;  2,  ureter; 
3,  spermatic  vessels;  4,  external  iUac;  5,  hypogastric  artery  (redrawn  from  Albarran). 


and  the  kidney  pelvis  fastened  directly  to  the  bladder.  When 
the  hydronephrotic  kidney  assumes  the  form  of  a  pocket  that 
hangs  down  beside  the  ureter,  a  direct  anastomosis  may  be  made 
between  the  lower  portion  of  the  sac  and  the  ureter.  In  these 
cases  valves  may  form  between  the  ureter  and  the  pelvis  of  the 
kidney;  such  valves  may  generally  be  destroyed  by  incision. 
Israel  and  Albarran  have  advocated  the  suturing  together  of  the 
renal  pockets  that  sometimes  form,  in  cases  of  hydronephrosis, 
behind  the  ureteral  opening.  The  suturing  together  of  the 
pocket  should  be  done  in  such  a  manner  as  to  prevent  the  urine 


SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS   331 

from  accumulating  in  the  back  part  of  the  pouch.  In  order  that 
these  operations  be  successful  it  is  necessary  that  the  renal  pocket 
be  shallow.  When  a  thick  pocket,  containing  some  of  the  kidney 
tissue,  exists  below  the  opening  of  the  ureter,  resection  of  the 
portion  of  the  kidney  beneath  the  ureteral  opening  may  be  per- 
formed. 

The  operation  of  Kiister^  is  only  performed  for  very  tight 
stricture  of  the  ureter.  The  ureter  is  cut  off  obliquely  below  the 
stricture,  an  incision  is  made  in  the  anterior  surface  of  the  ureter. 


Fig.   121. — Lumbar  iliac  incision  for  discovering  the  kidney  and  ureter  in  its  whole 
length  (after  Pierre  Duval). 

it  is  drawn  into  an  opening  in  the  anterior  surface  of  the  pelvis, 
flattened  out,  and  sewed  in  place.  The  primary  wound  in  the 
sac  of  the  pelvis  is  sewed  up  (fig.  122). 

Trendelenburg'  recommends  the  following  operation  for  hy- 
dronephrosis :  A  lumbar  incision  is  made,  the  sac  punctured  with 
a  trocar  and  opened  by  incision.  The  redundant  portion  of 
the  sac  and  the  included  portion  of  the  ureter  are  dissected  off. 
The  stump  of  the  ureter  is  then  sewed  into  the  lowest  portion  of 

^  Fnsch  and  Zuckerkandl,  1904. 

*  "  Deutsche  Zeitschrift  ftir  Chiriirg.,"  1904. 


33^    SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

the  remaining  sac.  The  incision  into  the  sac  is  then  sutured.  A 
small  drain  is  placed  in  the  ureter  and  another  in  the  pelvis,  both 
leading  out  through  lumbar  wounds. 


Fig.  122. — Ureteropyeloneostomy  (Kiister):  A — a,  b.  Sac-wall;  C,  incision  through 
ureter;  B — b,  c,  anterior  surface  of  split  ureter,  with  sutures  that  draw  up  surfaces  of 
ureter  to  wall  of  pelvis;  C — a,  upper  end  of  ureter;  a,  c,  anterior  incision  of  ureter; 
D,  ureter  laid  open  after  incision  (redrawn  from  Frisch  and  Zuckerkandl). 

An  illustration  (fig.  123)  is  also  furnished,  showing  the  method 
of  destruction  of  the  renal  valves  which  so  frequently  form 
between  the  pelvis  of  the  kidney,  and  the  ureteral  opening, 
where  a  hydronephrotic  sac  is  present.  It  is  easily  seen  how 
the  anterior  wall  of  the  valve  is  divided,  being  held  between  two 
forceps,  and  the  subsequent  suturing  which  takes  place.  In 
this,  as  in  several  other  of  the  operations  mentioned  above, 
retrograde  catherization  by  means  of  a  ureteral  catheter  will  be 
fotmd  useful. 


SURGERY  OF  THE  URETERS  AND  RELIEF    OF  HYDRONEPHROSIS    333 

It  should,  of  course,  be  borne  in  mind  that  in  the  past  neph- 
rotomy has  often  been  the  operation  of  choice  for  the  reHef  of 
hydronephrosis.  When  nephrotomy  is  performed,  however,  and 
the  sac  opened,  a  urinary  fistula  results  which  may  persist  for 
months.  To  a  great  extent  the  operation  of  nephrotomy  is  being 
superseded  for  the  reHef  of  retained  renal  secretion  by  some  of  the 
methods  mentioned  above.  Referring  to  these  operations  more  in 
detail,  a  remark  of  Israel's  may  well  be  quoted  here.  He  has  well 
stated  that  for  the  relief  of  hydronephrosis  it  is  necessary  to  remove 
the  cause.  In  a  large  proportion  of  the  operations  for  the  relief 
of  hydronephrosis,  anchorage  of  the  kidney  in  a  proper  position 


Fig.  123. — Operation  for  incision  and  suture  of  renal  valve  (redrawn  from  Pierre  Duval). 

is  required.  Rarely,  although  occasionally,  it  alone  may  suffice, 
but  ordinarily  it  should  be  performed  in  connection  with  some 
other  operation.  Albarran  considers^  that  the  three  most 
useful  operations  are  those  for  the  resection  of  the  sac,  of 
lateral  anastomosis  of  the  ureter,  and  pyeloplication,  which 
is  the  operation  of  Israel. 


1  "  Transactions  in  Urology,"  1904. 


334  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

In  resection  of  the  sac,  the  sac  having  been  punctured  and 
emptied,  the  clamp  is  placed  as  shown  in  the  illustration  (fig.  124), 
the  sac  is  amputated,  lumbar  drainage  is  instituted,  and  a  ureter 
catheter  is  allowed  to  remain.  This  operation  was,  we  think, 
first  performed  by  Albarran.  The  operation  of  lateral  anastomosis 
is  easily  understood  from  the  illustrations.  The  ureteral  catheter 
in  No.  1 1  acts  as  a  splint  for  the  new  ureteral  orifice,  and  is  tempo- 
rarily fastened  in  place  by  a  thread  emerging  through  the  nephrot- 
omy wound.  In  suturing  the  orifice,  the  second  set  of  sutures  are 
used  to  reinforce  the  first. 


Fig.  124. — Operation  for  resection  of  hydronephrotic  sac  (redrawn  from  Pierre  Duval). 


The  operation  of  Israel  is  as  follows  ^ : 

The  operation  consists  of  the  following  steps: 

(i)  The  occlusion  of  the  pelvis  of  the  kidney  to  such  an  extent 

that  the  origin  of  the  ureter  lies  in  the  most  dependent  portion 

of  the  reservoir. 

^  James    Israel,    "  Chirurgische    Klinik    der    Nierenkrankheiten,"    May, 
1901. 


SURGERY  O^  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS    335 

(2)  The  lessening  of  the  volume  of  distended  pelvic  cavity  of 
the  kidney. 

(3)  The  forcing  down  of  the  upturned  neck  of  the  ureter. 

An  incision  is  made  into  the  posterior  wall  of  the  pelvis  for 
exploration,  and  then  sutured.  Catgut  sutures  are  then  inserted 
into  pelvis  of  the  kidney,    1.5  cm.  from  the  sutured  exploratory 


Fig.    125. — Operation  for  lateral  anastomosis  of  ureter  (redrawn  from  Pierre  Duval). 


incision,  each  being  separated  5  mm.  from  the  rest.  All  sutures 
pierce  the  walls  of  the  pelvis  of  the  kidney,  diverging  markedly. 
The  suture  is  brought  out  5  mm.  from  the  exploratory  incision, 
introduced  again  posterior  to  the  exploratory  incision  5  mm.  away, 
and  finally  brought  out  at  a  point  at  the  widest  distance  between 
the  hilum  of  the  kidney  and  outlet  of  pelvis.  When  these  sutures 
are  tied,  the  distended  wall  of  the  pelvis  is  no  longer  present,  and 
the  newly  formed  base  of  cavity  is  in  a  line  from  hilum  of  the  kid- 
ney to  the  mouth  of  the  ureter.  If  the  neck  of  the  ureter  is  turned 
upward,  the  following  operation  is  done  for  its  correction.  A  suture 
is  introduced  into  the  lower  wall  of  the  pelvis,  i  cm.  above  the 
angle  of  ureter,  is  carried  for  5  mm.  into  its  substance;  it  is  rein- 
serted below  the  point  of  angulation,  and  carried  for  several  mil- 
limeters into  the  muscular  wall,  and  then  brought  out.  After 
tying  this  suture  the  ureter  is  then  brought  down  to  its  proper 
position. 


336  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDROXEPHROSIS 

Class  II. — The  most  frequent  operations  to  be  considered 
under  this  head  are  those  ordinarily  performed  for  those  cases 
in  which,  as  the  result  of  injury,  the  lower  opening  of  the  ureter 
is  transplanted  into  another  portion  of  the  bladder  than  that  into 
which  it  originally  opened.  The  ureter  having  been  exposed  by 
whatever  seems  the  most  desirable  route  for  the  case  in  hand,  may 


Fig.  126. — Pyeloplication  and  ureter  correction.  Posterior  view  of  left  kidney. 
e.  Exploratory  incision;  S,  S,  sutures  for  the  pyeloplication  of  the  sac  ;  U,  suture  to  coi- 
rect  shape  of  ureter  (redrawn  from  James  Israel). 


be  made  to  enter  the  bladder  at  a  right  angle  or  in  an  oblique  di- 
rection, as  shown  in  the  accompanying  illustration  (fig.  127).  If 
it  is  made  to  enter  in  an  obhque  direction,  it  should  be  firmly 
fastened  by  sutures  carried  through  the  external  bladder- wall,  with- 


SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS  337 


out  penetrating  the  inner  coat  of  the  bladder,  for  an  inch,  when 
possible,  before  the  mouth  of  the  ureter  enters  the  bladder-cavity 
directly.  The  length 
of  the  adherence 
of  the  course  of  the 
ureter  to  the  blad- 
der tends  to  make 
the  bladder  act  as  a 
splint  to  the  ureter 
and  holds  the  latter 
in  place. 

Operations  have 
occasionally  been 
made  for  the  pur- 
pose of  transplant- 
ing the  mouth  of  the 
ureter  to  the  skin, 
the  vagina,  rectum, 
and      the      urethra. 

Qiir>'h    /-vt-»oi-of  i/-.nc    o t-£»     Fig.  127. — Showing- oblique  insertion  of  transplanted  Ureter 
OUCU    operations    are  into  bladder  (after  Biidinger). 

sometimes     per- 
formed to  give  temporary  relief  after  an  operation  for  malignant 
disease. 

The  most  common  operative  procedures  coming  in  this  class 
are  those  practised  for  the  transplantation  of  the  end  of  the  ureter 
into  another  portion  of  the  bladder,  as  just  described,  and  the 
operation  of  transplanting  the  mouth  of  the  ureter  into  the  intes- 
tinal canal.  At  the  present  time,  the  anastomosis  is  most  gener- 
ally made  into  the  rectum.  Such  anastomosis  is  ordinarily  per- 
formed for  the  relief  of  exstrophy  of  the  bladder.  Carl  ]Maydl 
was  the  first  to  suggest  that,  in  performing  such  anastomosis,  if  a 
portion  of  the  trigonum  is  removed  with  the  mouth  of  the  ureter, 
the  contractile  power  of  the  ureter  might  remain  unimpaired. 
This  method  has  been  modified  somewhat  by  Carl  Beck,  of  New 
York,  and  is  described  by  him  in  an  article  entitled  "  Rectal 
Anastomosis  of  the  Ureters."  ^  He  suggested  that  the  flap 
assume  a  rhomboid  instead  of  an  elliptic  shape,  which  would 
^  "  New  York  Medical  Journal,"  May  19,  1906. 


338  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 


permit  it  to  be  more  easily  attached  to  the  longitudinal  opening 

in  the  intestine. 

It   occasionally  happens   that  unilateral  implantation  of  the 

ureter  into  the  rectum  is 
indicated  for  conditions 
other  than  exstrophy  of  the 
bladder,  as  for  the  relief  of 
destructive  processes  caused 


Fig.  128. — Vesical  trigonum  exsected  after  intro- 
ducing catheters  into  the  ureters  (Beck). 


Fig.  129. — Lower  end  of  ureter  im- 
planted into  the  bowel  after  being  split 
(Beck). 


by  malignant  disease,  such  as  carcinoma  of  the  bladder  or 
ureteral  fistula.  In  these  cases,  according  to  Beck,  stenosis  is 
best  avoided  by  splitting  the  lower  end  of  the  ureter  before  placing 
it  into  the  slit  made  in  the  bowel.  The  transplanting  of  the  mouth 
of  the  ureter  by  making  a  slit  into  the  bowel  and  removing  the 
end  of  the  ureter  with  a  portion  of  the  trigonum  attached  (fig. 
128),  or  in  unilateral  cases  by  splitting  the  end  of  the  ureter  in  the 
manner  just  described,  is  the  method  by  which  the  ureter  is  in- 
vaginated  into  the  wall  of  the  bowel  and  sutured  there  (fig.  129), 


SURGERY  OF  THE  URETERS  AND  REUEF  OF  HYDRONEPHROSIS  339 

and  is  probably  preferable  to  any  procedure  that  involves  the  in- 
sertion of  a  mechanic  appliance. 

Inflammation  of  the  kidney,  the  result  of  an  upward  extension 
of  infection,  is  often  said  to  take  place  after  anastomosis  of  the 
lower  end  of  the  ureter,  but  this  result  does  not  necessarily  follow 


Fig.  130. — Various  methods  of  ureteral  anastomosis  :  a,  End-to-end  anastomosis  of  severed 
ureter  ;  b,  terminal  lateral  anastomosis  ;  c,  the  three  steps  in  the  operation  of  lateral  anasto- 
mosis (Pierre  Duval). 


in  all  cases.  The  statistics  of  Bouvee  showed  that  in  1903  the 
operation  of  ureteral  anastomosis  was  performed  in  iii  cases, 
with  7  deaths. 

A  study  of  the  histories  of  the  cases  on  record  lead  to  the  con- 
clusion that  the  various  anastomoses  on  the  upper  end  of  the 
ureter  into  some  other  portion  of  the  pelvis  of  the  kidney  than  it 


340  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

originally  occupied  is  often  attended  with  failure.  On  the  other 
hand,  anastomosing  of  the  lower  end  of  the  ureter  to  a  different 
position  in  the  bladder  wall  is  very  often  successful,  and  the  ureter 
functionates  in  a  natural  manner. 

Class  III. — Operations  for  Wounds  of  the  Ureter,  for 
Removal  of  Stone,  and  for  the  Relief  of  Strictures  of  the 
Ureter. — Wounds  of  the  ureter  may  involve  either  extremity, 
but  as  they  are  made  most  often  during  gynecologic  operations, 
they  are  most  likely  to  be  inflicted  along  the  mid  course  of  the 
ureter.  Longitudinal  wounds  of  the  ureter  have  a  tendency  to  heal 
spontaneously.  The  ureter  having  been  exposed,  as  previously 
mentioned,  a  few  sutures  should  be  taken  through  the  outer  layers 
of  the  ureter,  or  a  catheter  be  allowed  to  remain  in  the  pelvis  of 


Pig,     131. — Longitudinal  section  at  mouth  of  ureter  united  by  transverse  suture  (Berger  and 

Hartmann). 

the  kidney  for  a  few  days  to  act  as  a  splint  for  the  injured  tube. 
When  the  wounds  run  in  a  transverse  direction  and  the  ureter  has 
been  completely  severed,  the  procedure  will  be  more  difhcult. 

Various  suggestions  have  been  made  by  surgeons  as  to  the  best 
means  of  effecting  union  of  the  severed  ends.  Generally  speaking, 
the  same  procedure  is  followed  as  in  those  cases  in  which  the  intes- 
tine has  been  completely  severed.  The  two  severed  ends  may  be 
brought  in  apposition  and  sewed  together,  or  one  end  be  invag- 
inated  into  the  other.  Incisions  may  be  extended,  made  oblique, 
or  the  two  ends  may  be  zigzaged  into  each  other,  as  the  surgeon 
sees  fit.  The  different  methods  of  uniting  the  severed  ends  of  the 
ureter  are  well  shown  in  the  illustrations  accompanying  the  article 
(fig.  130). 


SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS   34 1 

For  removing  a  stone  from  the  ureter  the  longitudinal  incision 
is  the  preferable  one.  Occasionally,  operating  through  the  bladder, 
a  stone  may  be  removed  from  the  ureter  by  the  finger  or  by  the 
use  of  long  narrow  forceps  if  the  mouth  is,  as  occasionally  happens, 
dilated. 

In  operating  for  the  relief  of  stricture  of  the  ureter,  wherever 


Fig.  132. — Method  of  incising  and  suturing  stricture  of  ureter  (Berger  and  Hartmann). 


located,  a  longitudinal  incision  can  be  sewed  up  laterally,  so  as 
to  extend  the  diameter  of  the  ureter,  as  illustrated  in  the  cut 
(fig.  132).  This  was  suggested  by  Finger.  Another  method  for 
the  relief  of  stricture  of  the  ureter  is  its  gradual  distention  by  the 
passage  of  sounds  designed  for  that  purpose. 

Attempts  have  been  made  to  remove  the  ureter  completely 
when  the  tube  was  found  to  be  markedly  diseased.  The  term 
ureterotomy  is  applied  to  a  simple  incision  in  the  ureter,  whereas 
ureterectomy  refers  to  total  ablation  of  the  ureter.  Resection  of 
the  canal  has  been  performed  comparatively  rarely.  It  is  con- 
sidered good  practice,  at  the  present  time,  in  performing  neph- 
rectomy, to  remove  also  large  portions  of  the  ureter  when  the 
tube  is  apparently  diseased. 

Such  a  condition  as  tumor  of  the  pelvis  of  the  kidney,  accord- 
ing to  Paul  Wagner,^  not  infrequently  has  a  ureter  diseased  at 
both  ends,  with  healthy  tissue  between.  When  practical,  in 
performing  an  exploratory  operation  on  the  kidney,  or  a  neph- 
rectomy, the  opening  of  the  ureter  should  be  examined  and 
^  Frisch  and  Zuckerkandl. 


342  SURGERY  OF  THE  URETERS  AND  RELIEF  OF  HYDRONEPHROSIS 

some  instrument  passed  through  its  canal  into  the  bladder.  The 
lower  end  of  it  can,  of  course,  be  examined  through  the  cystoscope, 
and  now  that  ureteral  catheterization  is  being  performed  so  fre- 
quently, it  is  not  only  furnishing  aid  in  the  performance  of  many 
operations  on  the  kidney  and  the  ureter  for  the  purposes  of  drain- 
age and  for  diagnosis,  but  also  in  furnishing  knowledge  as  to  the 
condition  of  the  ureter  itself.  The  surgeon  in  performing  ureterec- 
tomy will  necessarily  have  to  be  guided  by  the  conditions  surround- 
ing any  given  case.  It  is  seldom  necessary,  in  performing  ureter- 
ectomy, to  entireh^  remove  the  portion  which  enters  the  bladder. 
If  such  should  be  the  case,  a  straight  median  incision  is  made  in 
the  posterior  wall  of  the  bladder,  and  a  partial  resection  of  the 
bladder  performed.  • 


CHAPTER  XIX 

ANATOMY,   PHYSIOLOGY,    AND     PATHOLOGY   OF   THE 

BLADDER 

ANATOMY  AND  PHYSIOLOGY 

The  bladder  is  a  hollow  viscus,  lying  in  the  anterior  portion  of 
the  pelvis.  It  serves  as  a  receptacle  for  the  urine,  which  drains 
downward  through  the  ureters,  and  retains  it  until  it  is  finally 
voided  through  the  urethra.  The  average  bladder  capacity  is 
about  one  pint,  but  this  varies  considerably  in  proportion  to  the 
size  of  the  body  and  according  to  the  habits  of  the  individual. 
The  viscus  is  so  constructed  as  to  permit  of  a  considerable  degree 
of  physiologic  distention;  and  it  may,  under  certain  conditions, 
become  enormously  distended.  When  empty,  it  lies  posterior 
to  the  pubic  arch,  its  upper  surface  only  being  covered  by  the 
peritoneum;  but  when  distended,  its  cavity  lies  above  the  arch, 
and  the  superior  and  posterior  aspects  become  invested  by  peri- 
toneum. Its  summit  is  attached  to  the  abdominal  wall  by  a 
fetal  cord  or  filament,  the  urachus.  The  bladder  is  supported 
by  four  true  ligaments,  all  derived  from  the  rectovesical  pelvic 
fascia. 

The  bladder  is  made  up  of  four  coats,  a  serous  or  serofibrous,  a 
muscular,  a  submucous,  and  a  mucous. 

The  serous  coat  is  derived  from  the  peritoneum  and  is,  as  already 
mentioned,  incomplete.  It  is  moderately  well  supplied  with 
blood-vessels  and  nerve-fibers.  The  muscular  coat  is  made  up 
entirely  of  smooth  involuntary  muscle.  Diagrammatically  it  is 
divided  into  an  external  longitudinal,  a  middle  circular,  and  an 
internal  longitudinal  layer;  anatomically  no  distinction  can  be 
made  between  these  layers,  which  are  blended  into  one  another 
and  associated  with  numerous  oblique  fibers  so  that  contraction  of 
the  bladder  takes  place  in  every  direction.  In  the  lower  part  of 
the  circular  layer,  however,  the  fibers  thicken  distinctly  around 
the  urethral  opening,  just  posterior  to  the  prostate  gland,  where 

343 


344       ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY   OF   BLADDER 

they  form  a  distinct  muscle — the  sphincter  vesicae.  The  submu- 
cous coat  is  made  up  of  a  dense  layer  of  areolar  connective  tissue 
in  which  yellow  elastic  fibers  occur  in  great  abundance.  This 
coat  is  highly  vascular  and  contains  many  nerve  trunks.  The 
mucous  coat  of  the" bladder  is  made  up  of  a  thick  layer  of  transi- 
tional epithelium,  so  arranged  that  when  the  bladder  is  collapsed, 
the  cells  pile  up  together;  when  distended,  they  glide  over  one 
another  so  that  the  entire  surface  is  still  invested  by  epithelium; 
in  a  greatly  distended  organ,  therefore,  the  mucosa  may  be  cov- 
ered only  by  a  layer  of  simple  squamous  epithelium. 

The  blood-supply  of  the  bladder  is  derived  from  the  superior 
and  inferior  vesical  arteries  and  from  branches  of  the  hypogastric. 

The  nerve-supply  of  the  bladder  comes  from  the  third  and 
fourth  lumbar  and  the  second  sacral  spinal  nerves  and  from 
branches  of  the  hypogastric  sympathetic  plexus. 

The  function  of  the  bladder  is  largely  that  of  a  passive  reservoir 
into  which  the  urine  is  ejected  by  the  ureters.  Its  muscular 
contractions  are,  to  a  greater  or  less  degree,  under  voluntary 
control,  although  dependent  largely  on  the  smooth  muscle  coat, 
which  is  innervated  by  the  sympathetic  nervous  system.  These 
movements  are  inaugurated  and  intensified  by  the  voluntary 
contraction  of  the  abdominal  muscles.  The  external  sphincter 
of  the  bladder  seems  also  to  be,  at  least  to  a  considerable  degree, 
under  voluntary  control.  The  contraction  of  the  bladder  is,  how- 
ever, undoubtedly  inaugurated  as  a  reflex  act  following  stimula- 
tion of  the  sensory  nerves  of  the  urethra  by  the  escape  of  a  few 
drops  of  urine  into  it.  The  spinal  center  that  controls  the  con- 
tractions of  the  bladder  is  probably  situated  between  the  second 
and  fifth  lumbar  segments. 

PATHOLOGY  OF  THE  BLADDER 
Congenital  Malformations. ^ — The  most  important  of  these  abnor- 
mities assumes  the  form  of  aplasia  or  exstrophy.  In  this  condi- 
tion the  anterior  wall  of  the  bladder  and  of  the  abdomen  is  defec- 
tive and  the  posterior  wall  of  the  bladder,  usually  showing  the 
urethral  orifices,  is  exposed  to  the  air.  The  condition  is  generally 
associated  with  epispadias,  or  with  other  congenital  defects  of 
development  in  this  region.     Cases  of  permeable  urachus,  in  which 


PLATE  X 


Cross-section  through  normal  male  pelvis. 


PATHOLOGY  O'P   THE  BLADDER  345 

the  urine  may  be  discharged  through  the  umbiHcus,  are  occasion- 
ally seen.  The  condition  occurs  most  frequently  when  more  or 
less  atresia  of  the  urethra  exists.  Abnormities  in  the  shape  and 
size  of  the  bladder  are  not  infrequently  seen,  usually  at  autopsy; 
they  are  anatomic  curiosities  and  have  but  little  clinical  impor- 
tance. 

Acquired  Malformations. — ^The  most  frequent  acquired  malfor- 
mation of  the  bladder  is  a  chronic  dilatation  that  follows  habitual 
overdistention  of  the  viscus.  This  occurs,  as  a  rule,  as  a  result 
of  obstruction  to  the  urinary  outflow,  as  from  urethral  stricture 
or  hypertrophy  of  the  middle  lobe  of  the  prostate.  The  condi- 
tion is  frequently  associated  with  more  or  less  ulceration  of  the 
mucous  membrane,  and  with  alkaline  fermentation  of  the 
urine  when  infection  has  taken  place.  Dilatation  of  the 
bladder,  when  of  long  standing,  is  generally  associated  with  thin- 
ning and  atrophy  of  the  muscular  coat,  and  with  more  or  less 
interstitial  hyperplasia.  In  the  early  stages  of  the  disease  con- 
siderable hypertrophy  of  the  muscular  coats  may  take  place,  but 
this  commonly  terminates  in  muscular  atrophy  and  fibrous  re- 
placement, with  a  greater  or  less  degree  of  inflammatory  change. 

Vesical  diverticula  may  form  as  a  result  of  localized  areas  of 
muscular  atrophy,  such  as  may  follow  embolism  of  the  nutrient 
vessels  or  fibrous  proliferation  occurring  in  inflammatory  dis- 
ease associated  with  overdistention. 

Considerable  distortion  of  the  bladder  may  take  place  in  the  female 
in  cases  of  vaginal  cystocele  or  in  either  sex  when  the  bladder  is 
included  in  a  hernial  protrusion,  or  where  foreign  bodies  are  found 
in  it. 

Rupture  of  the  bladder  may  occur  as  the  result  of  either  acute 
or  chronic  overdistention.  It  may  arise  spontaneously  or  follow 
infliction  of  a  traumatism,  oftentimes  of  very  slight  degree.  It 
not  uncommonly  takes  place  in  certain  comatose  conditions,  as 
in  alcoholism,  in  which  overdistention  of  the  bladder  is  associated 
with  some  injury.  The  writers  have  seen  a  case  of  vesical  rupture 
follow  the  simple  fall  of  an  intoxicated  man.  The  accident  is 
much  more  likely  to  occur  when  ulceration  or  some  other  disease 
process  has  brought  about  a  lowering  of  the  resistance  of  the 
bladder-wall. 


34^      ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY   OF    BLADDER 

Perforations  of  the  bladder  permit  the  more  or  less  rapid  extrava- 
sation of  urine  into  the  surrounding  tissues.  They  may  be  caused 
by  stab  or  gunshot  wounds,  by  direct  or  indirect  traumatism,  as 
in  fracture  of  the  pelvis,  or  as  a  result  of  ulceration  or  neoplasm 
of  the  bladder  or  adjacent  viscera.  A  perforation  into  the  peri- 
toneal cavity  is  usually  followed  by  a  rapid  and  often  fatal  peri- 
tonitis, and  when  the  puncture  occurs  in  the  lower  quadrant, 
urinary  extravasation  into  the  pelvic  structures  and  fascia  takes 
place.  This  often  results  in  the  production  of  gangrenous  in- 
flammations or  in  the  formation  of  vesicorectal  or  vaginal 
fistulae. 

Atony  of  the  Bladder. — Weakness  of  the  muscles  of  the 
bladder-wall  is  usually  due  to  overdistention.  It  may  be  due  to 
a  natural  atrophy  of  the  muscular  tissues,  which  normally  occurs 
in  old  people,  and  which  has  been  so  carefully  investigated  by 
Chiencanowski,  in  a  work  already  referred  to  by  us,  who  found 
in  old  people  only  about  two-thirds  of  the  normal  amount  of  mus- 
cular tissue  was  apt  to  be  present.  .  It  may  be  due  to  a  disease 
of  the  nervous  system,  such  as  neurasthenia,  and  it  may  follow 
conditions  giving  rise  to  exhaustion,  such  as  various  forms  of 
fevers.  It  is  frequently  found  allied  with  such  conditions  as 
urinary  obstruction  or  cystitis.  It  is  more  often  seen  in  women 
than  in  men,  not  infrequently  following  such  a  condition  as  preg- 
nancy. It  is  occasionally  seen  after  influenza  as  a  sequela  to  this 
disease.  It  is  characterized  generally  by  overdistention  and  very 
much  diminished  expulsive  power  in  the  passage  of  the  urine. 

Diagnosis. — A  history  of  the  case,  the  slowness  of  passage  of 
urine,  even  if  bladder  is  catheterized,  and  the  presence  of  overdis- 
tention. Patients  generally  pass  little  urine  with  this  condition, 
and  that  voided  is  apparently  an  overflow,  and  is  liable  to  mis- 
lead the  medical  attendant  as  to  the  condition  present  unless  the 
catheter  is  used.  When  percussion  and  palpation  of  the  abdo- 
men show  fullness  over  the  bladder  region,  it  is  generally  advis- 
able to  use  a  catheter  to  aid  in  the  diagnosis  rather  than  to  be 
misled  through  trusting  too  much  to  the  history  of  any  given 
case. 

Treatment. — The  treatment  necessarily,  to  a  considerable  ex- 
tent, consists  in  treatment  of  the  underlying  causative  factors. 


PATHOLOGY  OF  THE  BLADDER  347 

such  as  of  any  cystitis  that  may  be  present,  or  that  directed  toward 
the  relief  of  the  urinary  obstruction.  The  internal  administration 
of  certain  nerve  tonics,  unless  their  use  is  otherwise  counterindi- 
cated,  is  beneficial.     The  following  prescription  is  useful : 

Tincture  of  nux  vomica. 2  drams 

Tincture  of  cantharides i  dram 

Compound  tincture  of  cinchona  to  make  4  ounces. 
SiG. — One  dram  three  times  daily,  in  water,  before  meals. 

As  regards  local  measures,  the  most  useful  is  vibratory  massage 
applied  by  the  hand  on  the  abdomen  over  the  bladder  region.  The 
use  of  static  electricity,  both  to  the  spine  and  over  the  abdomen, 
may  be  attended  with  good  results.  In  these  cases  the  utmost 
regularity  should  be  observed  as  to  emptying  the  bladder  at  cer- 
tain specified  times. 

Incontinence  of  Urine  in  Children. — Incontinence  of  urine 
in  children  generally  occurs  at  night.  It  is  often  associated  with 
organic  disease  of  the  urinary  tract,  but  it  is  usually  due  to  insuffi- 
cient inner^^ation  of  the  compressor  urethrae  muscle.  The  treat- 
ment of  this  condition  is  both  general  and  local.  Internally, 
belladonna  and  strychnin  are  the  two  most  popular  remedies;  the 
administration  of  these  drugs,  however,  is  not  always  followed 
by  relief.  Locally,  faradization  of  the  suprapubic  region  and 
the  perineum  has  often  been  recommended.  Massage,  similar  to 
massage  of  the  prostate  in  the  region  of  the  seminal  vesicles,  has 
been  highly  lauded  by  a  German  specialist.  It  is  recommended 
also  that  care  be  used  to  avoid  pressure  of  the  bed-clothing  on  the 
bladder  region,  and  habits  of  emptying  the  bladder  at  regular 
intervals  should  be  formed.  In  every  case  the  child  should  fully 
empty  the  bladder  before  going  to  bed,  and  the  amount  of  fluid 
taken  during  the  afternoon  and  evening  should  be  restricted.  Men- 
tal control  should  be  inculcated,  and  all  local  irritations,  as  from 
vulvitis  or  proctitis,  relieved. 

The  writers'  experience  with  this  class  of  cases  seems  to  show 
that,  if  examined  carefully,  some  abnormal  condition  of  the  gen- 
eral system  will  be  found,  which,  if  cured,  will  usually  result  in 
relief  of  the  incontinence.  Thus  a  considerable  number  of  cases 
are  relieved  or  cured  by  circumcision  or  by  successful  treatment 
of  a  urethritis.     An  examination  of  the  blood   will  frequently 


348      ANATOMY,    PHYSIOLOGY,    AND   PATHOLOGY    OF    BLADDER 

reveal  the  presence  of  anemia  or  malaria,  which  may  act  as  pre- 
disposing causes. 

These  or  similar  existing  conditions  should  receive  appropriate 
treatment,  associated  with  measures  that  tend  to  improve  the 
general  health,  such  as  cold  sponge-baths.  The  internal  adminis- 
tration of  nerve  tonics,  such  as  the  phosphates,  has,  in  the  writers' 
experience,  given  excellent  results.  Raising  the  foot  of  the  bed 
so  as  to  keep  the  urine  away  as  much  as  possible  from  the  neck  of 
the  bladder  is  generally  of  benefit. 

Cystitis. — Inflammation  of  the  bladder,  or  cystitis,  may  be  a 
limited,  localized  process,  affecting  only  a  small  area  of  the  blad- 
der surface,  or  it  may  be  a  generalized  process  that  involves 
the  entire  mucous  membrane.  Cystitis  is  most  frequently  caused 
by  the  presence  of  infectious  micro-organisms,  although  traumatic 
cystitis  is  by  no  means  unknown;  even  in  the  latter  instance,  bac- 
teria that  subsequently  enter  usually  play  an  important  role. 
The  disease  generally  arises  as  the  result  of  infection  extending 
inward  from  the  urethra;  when,  alkaline  decomposition  of  the 
urine  occurs,  it  acts  as  an  additional  etiologic  factor.  Cystitis 
is  frequently  induced  by  careless  instrumentation,  as  a  result  of 
which  bacteria  are  directly  introduced  into  the  bladder  cavity, 
or  some  injury  inflicted  on  its  mucous  membrane  that  may  first 
cause  a  mechanic  and  not  an  infectious  process  to  manifest 
itself. 

Following  injuries  to  the  mucous  membrane  of  the  bladder 
it  should  be  remembered  that  bacteria,  often  of  a  pathogenic 
variety,  are  excreted  normally  in  the  urine.  Under  healthy 
conditions  these  give  rise  to  no  disturbance;  but  in  the  presence 
of  an  abraded  mucous  membrane,  infection  and  cystitis  are  very 
likely  to  develop. 

A  certain  number  of  cases  of  cystitis  occur  in  consequence  of 
infection  extending  downward  from  the  kidney.  This  is  partic- 
ularly true  of  certain  instances  of  renal  tuberculosis  and  pyoneph- 
rosis. 

The  disease  occurs  very  commonly  as  a  result  of  the  presence  of 
foreign  bodies  in  the  bladder.  These  may  be  particles  introduced 
from  without,  or,  in  many  cases,  are  stones  formed  either  in  the 
kidney  or  in  the  bladder  itself.    Infection  with  more  or  less  urinary 


PATHOLOGY  OF  THE  BLADDER  349 

decomposition  is  practically  certain  to  develop  in  nearly  all  such 
cases. 

Simple  catarrhal  inflammation  of  the  bladder  is  a  much  more 
prevalent  condition  than  is  generally  supposed.  It  most  com- 
monly arises  as  the  result  of  inflammation  set  up  by  a  urine  that 
possesses  irritating  chemic  or  physical  characteristics.  This 
occurs  in  such  conditions  as  oxaluria,  in  high  concentration  of 
the  urine,  or  when  acid  phosphates  are  present  in  excessive 
amounts.  Catarrhal  cystitis  is  also  an  uncommon  accompani- 
ment of  the  acute  exanthemata. 

The  pathologic  lesions  present  in  cystitis  vary  more  in  degree 
than  in  character  according  to  the  etiologic  factor  in  each  partic- 
ular instance.  The  simple  catarrhal  condition  is  manifested  by 
congestion  of  the  blood-vessels,  swelling  of  the  mucous  membrane, 
and  usually  more  or  less  desquamation  of  the  epithelium.  Leuko- 
cytes and  pus-cells  appear  in  small  numbers,  and  unless  the  con- 
dition is  of  long  standing,  the  other  coats  of  the  bladder  present 
little,  if  any,  change. 

Purulent  cystitis  may  follow  as  a  direct  result  of  the  catarrhal 
disease  or  it  may  develop  independently.  In  this  form  of  cystitis 
marked  erosion  of  the  bladder  epithelium  takes  place ;  the  blood- 
vessels of  the  submucosa  become  intensely  hyperemic,  and  there 
is  an  abundant  exudation  of  pus-cells,  extending  not  only  through 
the  mucosa  into  the  cavity  of  the  bladder,  but  also  into  the  sub- 
mucous and  muscular  coats.  Ulceration  develops  sooner  or  later, 
and  is  generally  associated  with  alkaline  fermentation  of  the  urine, 
so  that  a  precipitate  of  triple  phosphates  and  other  urinary  salts 
is  deposited  on  the  inflamed  and  eroded  mucous  surface.  In  long- 
standing or  active  cases  the  ulceration  may  extend  from  the 
submucosa  into  the  muscle- walls ;  hyperplasia  of  connective  tissue 
almost  invariably  follows,  and  results  in  muscular  atrophy  and 
marked  fibrous  thickening  of  the  bladder- wall.  This  thickening  is 
directly  associated  with  greatly  impaired  muscular  force  and 
diminished  elasticity  of  the  bladder-walls.  Even  when  healing 
takes  place  and  the  mucous  membrane  is  completely  covered 
with  newly  formed  epitheUum,  the  interstitial  hyperplasia  in  the 
muscle  coat  may  have  been  so  great  as  to  preclude  the  restoration 
of  proper  muscular  control  of  the  bladder. 


350      ANATOMY,   PHYSIOLOGY,    AND    PATHOLOGY   OF    BLADDER 

Phlegmonous  cystitis  occurs  in  very  active  and  virulent  infec- 
tions, or  in  those  cases  in  which  trophic  disorders  are  associated 
with  overdistention,  as  is  well  exemplified  in  many  spinal  lesions. 
Usually  when  active  gangrenous  destruction  of  the  bladder-wall 
takes  place,  if  the  patient  survives  long  enough  perforation 
results. 

Tubercular  cystitis  is  by  no  means  a  rare  condition.  As  a  rule, 
it  is  secondary  to  tubercular  disease  of  the  seminal  vesicles,  pros- 
tate, or  urethra  or  to  renal  tuberculosis.  It  must  be  remembered, 
however,  that  purely  tubercular  infections  of  the  kidney  do  not 
tend  to  set  up  tubercular  cystitis  unless  mixed  infection  occurs, 
or  some  mechanic  factor,  as  overdistention  or  instrumentation, 
acts  as  a  predisposing  cause. 

The  pathologic  changes  in  tubercular  cystitis  differ  but  little 
from  those  seen  in  the  other  forms  of  cystitis,  except  that  tuber- 
cles occur.  The  tubercular  ulcerations  are  usually  not  sufficiently 
characteristic  to  justify  an  absolute  diagnosis  from  their  gross 
appearance  alone.  This  is  doubtless  due  to  the  fact  that  mixed 
infection  almost  invariably  takes  place  and  the  lesions  no  longer 
remain  of  a  characteristically  specific  type.  Inspection  with  the 
cystoscope  is,  however,  of  great  diagnostic  assistance,  and  at  times 
may  be  conclusively  final.  Where  tubercular  cystitis  is  suspected, 
one  should  carefully  search  for  other  tubercular  lesions  elsewhere 
and  a  bacteriologic  examination  of  the  urine  should  be  always  made. 

Acute  syphilitic  disease  of  the  bladder  is  infrequent.  When  it 
exists,  it  is  so  closely  associated  with  mixed  infections  as  to  ren- 
der its  diagnosis  in  local  lesions  impossible,  but  the  contracted 
bladder  common  in  old  cases  of  syphilis  is  a  frequent  and  impor- 
tant condition. 

Tumors  of  the  Bladder. — The  stud}^  of  this  subject  has  received 
a  new  impetus  on  account  of  the  greater  facility  with  which  the 
condition  may  now  be  diagnosticated  while  still  in  a  stage  afford- 
ing some  hope  for  favorable  results  of  treatment.  At  the  same 
time  the  use  of  the  operating  cystoscope,  and  of  other  modern 
surgical  methods,  has  placed  in  the  operable  class  many  neoplastic 
lesions  of  the  bladder  which  up  to  very  recent  times  were  con- 
sidered absolutely  hopeless.  The  recent  publications  of  W^atson, 
Mandelbaum,   and    others  in  America,  and    those  of    Albarran, 


PATHOLOGY  OF  THE  BLADDER  351 

Frisch,  Zuckerkandl,  and  Stoerk  abroad  have  reopened  the  entire 
question  in  an  entirely  new  hght. 

Growths  of  the  bladder  have,  nevertheless,  been  found  as  a  rare 
condition  in  our  personal  experience,  both  clinical  and  post- 
mortem, but  the  growing  importance  of  the  subject  is  now  such 
as  to  demand  more  than  passing  attention. 

Neoplasms  of  the  bladder  may,  for  clinical  purposes,  be  best 
discussed  as  innocent  and  malignant  and  as  primary  or  secondary. 
True  metastatic  tumors,  as  pointed  out  by  Mandelbaum,^  are 
unusual. 

Innocent  Tumors. — Innocent  tumors  of  the  bladder,  of  course, 
occur  only  as  primary  growths,  except  where  virtual  invasion 
of  the  bladder  may  result  from  the  extension  of  an  adjacent 
turtior  so  that  compression  of  the  bladder  follows.  As  an  example, 
one  might  cite  osteomata  or  chondroma  springing  from  the  pelvic 
girdle. 

Papilloma  is  unquestionably  the  most  frequent  and  most 
important  innocent  tumor  of  the  bladder.  It  is  composed  of 
an  elementary  villus  of  connective  tissue  which  originates  from 
the  submucosa  of  the  viscus,  growing  inward  and  investing  itself 
with  a  sheet  of  epithelium  which  in  most  cases  retains  the  general 
character  of  the  transitional  epithelium  of  the  cystic  mucosa. 
In  some  cases,  however,  the  epithelial  coat  is  made  up  of  simple 
or  stratified  columnar  epithelium.  As  a  rule,  these  growths  are 
pediculated,  though  occasionally  one  finds  sessile  masses  of  this 
variety.  They  are  generally  highly  vascular,  the  blood-vessels 
being  supported  by  the  scanty  connective-tissue  framework; 
they,  therefore,  bleed  readily  when  injured.  The  tumor  commonly 
originates  as  a  small  and  slowly  growing  excrescence,  generally 
situated  near  the  trigone,  but  if  not  promptly  removed,  they  are 
very  prone  to  extend  rapidly  and  may  eventually  involve  the 
entire  surface  of  the  bladder,  as  shown  in  Plate  XI.  As  a  result 
of  the  villous  nature  of  the  growth,  crystals  and  deposits  of  urinary 
salts  are  very  likely  to  take  place  about  them  and  may  so  cause 
relatively  early  disturbance  of  a  recognizable  nature.  Undoubt- 
edly, bits  of  these  tumors  so  detached  oftentimes  form  the  nucleus 
of  stone  formation. 

^  "Surgery,  Gynecology,  and  Obstetrics,"  Sept.,  1907,  p.  315. 


352 


ANATOMY,    PHYSIOUOGV,    AND    PATHOLOGY    OF    BLADDER 


Papillomata  show  a  well-recognized  tendency  to  return,  even 
after  apparently  complete  removal,  and  for  this  reason  we  advo- 
cate the  more  active  methods  of  surgical  treatment,  even  m  the 
earlv  stages,  for  this  variety  of  tumor.  Furthermore,  there  is 
no  question  but  that  they  may  eventually  become  the  seat  of 
mahgnant  alterations  which  form  the  nidus  of  cancer  formation. 
The  diagnosis  is  usually  easy,  fortunately,  oecause  of  the  charac- 
teristic gross  appearance  with  the  cystoscope  and  also  since  the 
growth  ordinarilv  causes  a  good  deal  of  irritation,  which  attracts 
the  patient's  attention  to  the  bladder.  Occasionally  bits  of  the 
vilU  mav  become  detached  and  swept  oflf  in  the  urine,  appearmg 
in  such'condition  as  to  permit  of  microscopic  exammation  and 

absolute  diagnosis. 

Fibroma.-This  tumor  is  found  but  very  rarely,  and  is  seen 
mostlv  in  the  neighborhood  of  the  trigone.  It  is  found  develop- 
in-  in  the  submucosa  or  from  the  muscle  coats,  and  ordinarily  is 
covered  over  bv  the  mucous  membrane,  which  does  not  become 
attached  to  the' growth  except  as  a  result  of  secondary  inflamma- 
tion The  tumors  are  generally  of  small  size,  and  the  only  cases 
which  have  appeared  in  the  experience  of  the  authors  have  been 
associated  with  general  fibromatosis. 

■  Myxomata  of  the  bladder  are  also  infrequent,  and  develop  m 
much  the  same  location  and  way  as  the  fibroma.  They  are  more 
apt  to  grow  to  tumors  of  considerable  size,  and  in  most  cases  are 
closelv  allied  to  myxosarcoma. 

Myomata  of  the  bladder  have  been  obser^^ed,  but  the  authors  have 
never  seen  a  case.  They  are  reported  as  of  the  smooth  muscle  vari- 
ety, and  develop  within  the  muscular  or  fibrous  coats  of  the  organ. 
The  malignant  tumors  of  the  bladder  are  reported  with 
greatlv  variable  frequency  by  various  obser^^ers,  largely  since 
some  'include  among  the  malignant  growths  most,  if  not  all,  tne 
papillomata  and  some  the  myxomata  as  well.  As  we  have  pointed 
out,  the  papillomata  are  no  more  to  be  considered  as  primarily  ma- 
lignant in  the  bladder  cavity  than  they  are  when  they  occur  as 
primary  growths,  for  example,  on  the  skin  or  genital  mucosa. 
None  the  less  the  frequency  with  which  papillomata  become  mahg- 
nant should  be  always  borne  in  mind. 

In  our  experience  by  far  the  larger  number  of  primary  mahgnant 
tumors  of  the  bladder  have  been  secondary  and  not  primary  in 


PLATE  XI 


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PATHOLOGY  OF  THE  BLADDER  353 

the  bladder.  As  stated  by  some  authors,  metastatic  tumors  of 
the  bladder  are  relatively  infrequent,  but  the  organ  is  especially 
prone  to  become  involved  by  extension  from  tumors  of  the  uterus, 
Fallopian  tubes,  ovary,  vagina,  and  notably  from  primary  tumors 
of  the  prostate  gland,  a  fact  to  which  we  have  called  especial 
attention  in  a  previous  publication.  The  importance  of  this 
observation  is  self-evident  since,  where  the  growth  is  but  an  exten- 
sion from  tumors  primary  in  other  tissues,  but  little  more  than 
temporary  and  palliative  results  are  to  be  expected  as  a  result 
of  treatment  of  the  bladder  growth  alone. 

In  regard  to  the  primary  malignant  growths  of  the  bladder, 
Mandelbaum  makes  the  important  statement  that,  as  a  rule,  they 
remain  more  or  less  localized  for  comparatively  long  periods, 
and,  therefore,  operative  measures  of  a  vigorous  nature  are  more 
justified  than  in  instances  where  early  general  metastasis  is  prone 
to  follow. 

Cancer. — Carcinoma  is  undoubtedly  the  most  frequent  of  the 
malignant  new-growths  of  the  bladder.  As  we  have  already 
indicated,  the  tumor  is,  in  our  experience,  usually  secondary  and 
not  primary,  and  this  is  especially  so  where  a  primary  focus  is 
located  in  the  prostate.  Primary  cancer  of  the  bladder,  in  our 
opinion,  originates  most  frequently  as  a  result  of  malignant  trans- 
formation of  a  papilloma,  hence  the  histologic  variety,  in  a  con- 
siderable percentage  of  the  cases,  is  that  of  a  papillary  carcinoma. 
Adenocarcinoma  also  appears,  and  is  found  most  commonly  about 
the  trigone,  where  a  possible  genetic  relationship  to  the  elementary 
glands  located  here  seems  probable.  Epithelioma  springing  from 
the  vesical  mucosa  is  also  found :  it  is  usually  of  a  somewhat  less 
active  course  than  the  papillary  and  adenomatous  types  of  cancer, 
which  are  found  to  be  the  most  actively  malignant.  A  relation- 
ship between  the  development  of  epithelioma  and  the  irritation 
of  a  cystic  calculus  seems  to  be  definitely  established  in  some 
cases.  Epithelioma  and  scirrhous  carcinoma  as  well  are  found  to 
develop  in  the  edges  of  old  ulcerations  of  the  bladder.  In  such 
instances,  unless  the  ulcer  is  kept  under  frequent  inspection,  the 
malignant  transformation  is  apt  to  be  insidious  and  unexpected. 
This  affords  a  good  argument  for  radical  treatment,  particularly 
in  resistant  cases  of  chronic  ulcerative  cystitis,  especially  those 
occurring  after  the  fortieth  year. 
23 


354      ANATOMY,    PHYSIOIvOGY,    AND   PATHOLOGY    OF   BLADDER 

Perforation  of  the  bladder  wall  and  extension  of  the  growth 
to  adjacent  structures  are  frequent  in  bladder  cancer — rather  less 
so  in  certain  special  forms,  as  in  the  scirrhous  type,  than  in  others, 
notably  with  the  adenomatous  and  papillomatous  forms.  In 
practically  all  cases,  oftentimes  in  the  early  stages  of  malignant 
neoplasm  of  the  bladder,  a  cystitis  develops,  and  this  possible 
relationship  to  malignant  disease  should  be  considered  in  all  cases 
where  an  idiopathic  cystitis  has  developed.  Where  metastases 
take  place,  they  are  seen  first  in  the  pelvic  lymph-nodes,  as  a  rule. 

Sarcoma. — This  form  of  malignant  tumor  is  seen  rarely  except 
as  a  result  of  extension  of  growth  from  the  surrounding  structures. 
No  case  of  primary  sarcoma  has  appeared  in  the  writers'  personal 
experience,  and  where  metastatic  sarcoma  is  present,  it  is  most 
difficult  to  determine  anatomically  if  the  primary  site  be  in  the 
bladder  or  elsewhere.  Except  where  material  for  microscopic 
diagnosis  can  be  obtained,  or  where  the  growth  is  secondary  in 
nature,  differential  diagnosis  from  cancer  is  very  difficult  and  is 
relatively  unimportant,  since  the  methods  of  treatment  are  the 
same  in  both  instances  and  the  prognosis  does  not  differ  materially. 

The  more  rare  malignant  tumors  of  the  bladder,  such  as  endo- 
thelioma, teratoma,  and  hypernephroma,  do  not  demand  spe- 
cial attention  here,  both  because  of  their  great  infrequency  and 
because  the  methods  of  management  are  identical  with  those 
in  the  conditions  already  considered.  It  is  very  probable  that 
metastatic  hypernephroma  is  not  so  very  infrequent  (two  cases 
have  been  seen  by  the  writers),  on  account  of  the  marked  tend- 
ency of  this  tumor  to  metastasize  in  the  genito-urinary  organs. 

Syphilis  of  the  bladder,  to  which  reference  is  made  in  the  earlier 
part  of  this  volume  in  connection  with  the  cystoscopy  pictures,  is 
being  found  with  increasing  frequency,  owing  to  the  greater  famil- 
iarity with  the  cystoscope  and  the  larger  number  of  blood  ex- 
aminations being  made  for  the  Spirochaeta.  Its  most  prominent 
clinical  symptom  is  that  of  intermittent  hemorrhage;  it  may  give 
rise  to  ulcers  either  single  or  multiple,  yellow  or  purulent,  deep  or 
superficial.  Sometimes,  according  to  Gayet  et  Favre,  they  are 
polycystic,  the  general  appearance  resembling  syphilitic  ulcers  in 
other  portions  of  the  body.  They  may  also  resemble  sessile  or 
pediculated  tumors  if  they  are  gumma.  This  is  referred  to  again 
in  the  subject  of  Treatment  of  Bladder  Tumors. 


CHAPTER  XX 

DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE 

BLADDER 

The  necessity  of  first  making  a  correct  diagnosis  in  the  treat- 
ment of  bladder  diseases  cannot  be  too  strongly  dwelt  upon. 
Clinical  experience  has  served  but  to  ^strengthen  the  opinion  that 
carelessness  in  this  regard  is  all  too  common,  mistakes  as  to  the 
nature  of  the  existing  condition,  as  well  as  to  the  causative  factors, 
being  frequently  made.  Not  alone  isolated,  but  whole  series  of 
cases  are  constantly  being  brought  to  our  attention  in  which  the 
seat  of  the  trouble  is  primarily  in  the  spinal  cord,  and  the  cystitis 
followed  as  the  result  of  some  nervous  disorder  and  was  confounded 
with  primary  cystitis.  This  mistake  often  occurs  from  an  inability 
on  the  part  of  the  practitioner  to  recognize  and  properly  diagnose 
lesions  of  the  nervous  system.  lyocomotor  ataxia,  myelitis,  and 
various  other  degenerative  changes  in  the  spinal  cord  are  impor- 
tant and  frequent  factors  in  causing  bladder  disturbance.  Then, 
too,  there  are  seen  cases  of  bladder  disease  due  to  muscular  weak- 
ness— either  weakness  of  the  abdominal  muscles  or,  in  the  aged, 
a  weakness  due  to  atrophy  of  the  muscles  in  the  bladder-wall 
itself,  as  was  shown  by  the  very  interesting  work  of  Cienchanowski. 
It  is  evident,  in  these  conditions,  that  beyond  local  treatment, 
which  should  ordinarily,  in  these  cases,  be  of  the  mildest  char- 
acter, the  indications  are  to  conserve  and  increase,  so  far  as  possi- 
ble, the  activity  of  the  muscle.  At  the  same  time,  by  the  use  of 
baths,  massage,  a  well-selected  diet,  and  suitable  internal  medica- 
tion, pathologic  conditions  of  the  spinal  cord  or  of  other  portions 
of  the  nervous  system  may  be  improved  or  held  in  abeyance. 

Another  factor  that  is  very  often  concerned  as  a  cause  of  chronic 
inflammatory  conditions  of  the  bladder  is  late  syphilis.  The 
conditions  to  which  we  refer  to  are  more  often  found  in  old  syphi- 
litics. 

355 


356         DIAGNOSIS   AND   TREATMENT    OF    BLADDER   DISEASES 

CYSTITIS 

Acute  Cystitis. — For  clinical  purposes  cystitis  may  be  classified 
as  acute  and  chronic.  Acute  cystitis  is  rarely  found  existing  alone 
or  as  a  primary  condition,  being  almost  always  secondary  to  or 
accompanied  by  acute  inflammatory  affections  of  other  portions 
of  the  urinary  tract. 

Symptoms.— The  most  prominent  symptom  in  acute  cystitis  is 
painful  urination,  accompanied  by  pain  and  distress  referred  to 
the  lower  portion  of  the  abdomen.  The  urine  is  highly  colored, 
occasionally  tinged  with  blood,  and  contains  pus,  mucus,  des- 
quamated cells,  and  occasionally  necrotic  tissue  from  the  super- 
ficial layers  of  the  bladder.  Rigors  or  chilly  sensations  generally 
occur,  and  there  is  usually  a  rise  in  temperature. 

Diagnosis. — As  referred  to  in  the  section  on  Examination  of 
Patients,  in  making  the  diagnosis  it  is  necessary  to  exclude  acute 
urethritis,  stricture  of  the  urethra,  prostatic  obstructions  from 
below  and  attacks  of  gravel  from  above,  or  disease  of  the  nervous 
system  when  these  conditions  do  not  accompany  the  disorder. 
After  carefully  washing  out  the  urethra  as  far  as  the  compressor 
urethrse  muscle,  if,  on  urination  into  two  glasses,  the  fluid  in  both 
glasses  is  found  to  contain  pus,  it  is  very  positive  proof  that  cystitis 
or  some  inflammation  further  up  the  canal  is  present.  From 
stricture  of  the  urethra  it  may  be  differentiated  by  the  appro- 
priate methods,  which  will  be  described  in  the  diagnosis  of  stric- 
ture, and  it  may  be  differentiated  from  prostatic  obstructions 
by  a  careful  rectal  and  bimanual  examination  of  the  prostate. 
It  is  apparently  an  easy  matter  to  make  a  diagnosis  between  cys- 
titis and  difficult  urination  due  to  urinary  obstruction  caused  by 
an  enlarged  prostate;  mistakes  are,  however,  frequently  made, 
and  in  doubtful  cases  a  very  careful  examination  is  often  neces- 
sary. In  many  cases  of  simple  cystitis  the  ability  to  empty  the 
bladder  completely  or  in  part  still  remains. 

Gonorrheal  cystitis  in  its  clinical  symptoms  is  similar  to  other 
forms  of  the  acute  variety,  except  that  it  is,  as  a  rule,  more  severe 
in  degree  and  more  frequently  attended  with  difficulty  in  micturi- 
tion. 

Treatment  of  Acute  Cystitis. — ^The  indications  in  acute  cystitis 


CYSTITIS  357 

are  to  render  the  urine  as  unirritating  as  possible  to  the  inflamed 
bladder- wall,  to  relieve  spasms  and  pain,  and  to  administer  such 
remedies  as  tend  to  allay  irritation  of  the  mucous  membrane. 
Rest  in  bed  and  a  diet  consisting  largely  or  entirely  of  milk  in 
some  form  is  to  be  prescribed.  For  the  relief  of  spasm  warm 
applications  to  the  lower  part  of  the  abdomen,  hot  sitz-baths,  or, 
better  still,  when  possible,  partial  immersion  in  a  bath-tub  above 
the  waist,  and  urination  under  the  water,  will  be  found  of  benefit. 
Intemall}^,  small  doses  of  spiritus  setheris  nitrosi  and  salol,  repeated 
four  or  five  times  during  the  day,  are  advisable.  The  old-fashioned 
infusions  of  buchu  and  uva  ursi  still  have  their  advocates.  The 
writers  occasionally  prescribe  an  infusion  consisting  of  equal 
parts  of  flaxseed  and  elder  flower  flavored  with  licorice  root;  a 
small  handful  of  the  mixture  is  steeped  for  five  minutes  in  a  pint 
of  water,  and  this  is  taken  two  or  three  times  during  the  day.  The 
infusion  of  dried  violet  flowers,  as  recommended  in  the  treatment 
of  B right's  disease,  by  stimulating  the  activity  of  the  skin  and 
thus  relieving  the  kidney,  indirectly  benefits  the  bladder  or  one  of 
the  infusions  mentioned  in  the  treatment  of  chronic  cystitis  should 
be  tried.  Very  rarely  is  the  use  of  an  opiate  required  in  cystitis 
to  relieve  pain.  When  this  is  demanded,  a  rectal  suppository  of 
opium  should  be  preferably  given. 

In  the  local  treatment  of  acute  cystitis,  when  not  due  to  or 
associated  with  an  enlarged  prostate  or  with  stricture  of  the  ure- 
thra, the  use  of  the  catheter  is  but  rarely  required,  but  its  employ- 
ment may  be  followed  by  relief,  and  in  certain  cases,  especially 
those  of  gonorrheal  origin,  when  the  patient  is  unable  to  urinate, 
its  use  may  be  imperative.  Even  in  severe  cases,  however,  hot  sitz- 
baths  may  relieve  the  congestion  at  the  neck  of  the  bladder,  and 
the  power  to  urinate,  which  was  temporarily  lost,  be  regained 
after  an  hour  or  two.  In  cases  of  acute  cystitis  the  smallest  cathe- 
ter practicable  should  be  employed ;  and  in  lavage  of  the  bladder, 
which  is  often  done  in  conjunction  with  catheterization,  only 
unirritating  preparations  should  be  used.  Solutions  of  boric  acid 
or  of  mercury  bichlorid,  i :  10,000,  with  a  drop  of  phenol  to  the 
ounce,  or  mercury  and  phenol  combined  in  a  saturated  solution  of 
boric  acid  make  a  useful  fluid  for  the  purpose,  or  mercury  oxy- 
cyanid,  i  :  4000,  may  be  employed.  Later,  as  the  patient  im- 
proves, daily  or  triweekly  lavage  with  silver  nitrate,   i  :  10,000, 


358  DIAGNOSIS   AND   TREATMENT   OF    BLADDER    DISEASES 

may  be  used.  Internally,  as  the  acute  symptoms  subside,  oil 
of  sandalwood  may  be  administered.  Fluidextract  of  kava-kava, 
in  dram  doses,  repeated  three  or  four  times  a  day,  or  sandal- 
wood oil  and  kava-kava  combined,  may  be  prescribed.  Small 
doses  of  quinin  are  frequently  needed  from  the  onset,  but  very  large 
doses  of  quinin  tend  to  increase  the  congestion  in  inflammatory 
conditions  of  the  bladder.  The  use  of  the  salol,  if  introduced, 
should  be  continued  for  some  time. 

Chronic  Cystitis. — Diagnosis. — In  the  diagnosis  of  chronic  cys- 
titis the  same  steps  are  to  be  followed  as  are  taken  in  mak- 
ing the  diagnosis  of  acute  cystitis,  which  it  often  follows.  The 
cystoscope  is  coming  more  and  more  to  be  recognized  as  useful 
for  this  purpose.  In  a  large  proportion  of  the  cases  of  chronic 
cystitis  the  inflammation  will  be  found,  on  cystoscopic  examina- 
tion, to  be  confined  to  the  lower  portion  of  the  bladder — very 
rarely,  indeed,  is  the  vault  of  the  viscus  invaded.  A  varicose  con- 
dition of  the  veins  at  the  base  is  often  found,  and  the  general 
appearance  described  in  the  section  on  the  Pathology  of  Cystitis 
is  seen.  Attention  must  be  called,  however,  to  the  difficulties 
that  may  be  encountered  in  making  an  accurate  diagnosis  from 
cystoscopic  observation  unless  the  examiner  is  familiar  with  the 
appearance  of  the  normal  bladder. 

Treatment  of  Chronic  Cystitis. — Patients  suffering  from  chronic 
cystitis  are  generally  able  to  be  up  and  about,  and  in  some  cases 
are  benefited  by  exercise  in  the  open  air.  For  those  of  a  robust 
constitution,  such  exercises  as  swimming  are  sometimes  of  value 
in  hastening  the  convalescence  from  all  chronic  inflammatory 
conditions  of  the  bladder  and  urinary  tract.  A  careful  but  not 
necessarily  a  restricted  diet,  avoiding  especially  asparagus,  cab- 
bage, cauliflower,  rhubarb,  or  highly  seasoned  foods  and  all  irri- 
tating condiments,  is  to  be  advised.  The  general  health  of  the 
patient  should  receive  attention,  and  suitable  tonics  should  be 
prescribed.  If  blood  examination  shows  the  presence  of  malarial 
Plasmodia  or  the  existence  of  anemia,  proper  corrective  measures 
should  be  instituted. 

The  internal  treatment  of  chronic  cystitis  differs  somewhat 
from  that  of  the  acute  type.  Iron  in  an  unirritating  form, 
arsenic,  and  quinin  may  be  advantageously  administered.     The 


CYSTITIS  359 

various  balsamics  may  be  employed  with  benefit,  either  alone 
or  in  combination,  and  used  in  conjunction  with  the  infusions 
previously  suggested  as  serviceable  in  the  treatment  of  acute 
cystitis.  Fluidextract  of  kava  kava  in  dram  doses,  several  times 
a  day,  may  be  used  with  benefit. 

Such  good  results  have  attended  the  use  of  certain  infusions 
in  our  experience  that  we  give  here  some  formulas  for  the  same 
which  were  omitted  in  previous  editions  of  this  work,  the  use  of 
which  will  be  found  beneficial.  For  cystitis,  acute  and  chronic, 
the  following  is  recommended: 

Com  silk J  ounce; 

Flaxseed i  ounce ; 

2  drams  for  a  cup  of  infusion. 

Buchu  leaves J  ounce; 

Peppermint 2  drams; 

Sugar  (q.  s.  to  sweeten) ; 
2  drams  to  cup  of  boiling  water  three  times  a  day. 

Uva  ursi J  ounce; 

Cherry  stems 2  drams; 

Flaxseed ^  ounce ; 

2  drams  to  cup  of  boiling  water  three  times  a  day. 

The  following  has  a  somewhat  more  diuretic  and  stimulating 
action : 

Cubeb  berries,  bruised, 

Juniper  berries,  bruised each  ^  ounce. 

Two  teaspoonfuls  to  cup  of  boiling  water  three  times  a  day. 

As  a  diuretic: 

Couch  grass, 

Cut  licorice  root each  J  ounce; 

Marshmallow  leaves, 

Elder  flowers each   2  drams; 

4  drams  to  a  tea  cup  of  boiling  water  three  times  a  day. 

Local  Treatment. — The  local  treatment  is  of  great  importance 
in  this  condition.  Silver  nitrate  is  the  most  useful  of  the  local 
appUcations.  The  bladder  should  be  filled  with  from  four  to 
eight  ounces  of  a  very  weak  solution  of  silver  nitrate — not  stronger 
than  1 :  10,000  to  begin  with.  If  this  is  well  borne,  the  strength 
may  gradually  be  increased  to  i :  5000.  Silver  nitrate  is  very 
commonly  prescribed  in  solutions  of  too  great  strength.  These 
irrigations  of  the  bladder  should  be  made  from  two  to  four  times 


36o  DIAGNOSIS   AND   TREATMENT  OF    BLADDER   DISEASES 

a  week.  The  silver  nitrate  irrigation  should  not  be  followed  by 
one  of  boric  acid,  as  a  chemic  change  will  take  place  between  the 
two  solutions,  rendering  both  inert.  If  the  bladder  does  not  react 
well  to  silver  nitrate,  the  solution  next  in  favor  with  the  writers  is 
the  old  Ultzmann  mixture  of  zinc  sulphate,  phenol,  and  alum,  of  each 
from  I :  looo  to  i :  500.  A  few  applications  of  this  will  frequently  so 
far  improve  the  condition  as  to  permit  the  silver  nitrate  irrigation, 
which  previously  proved  too  irritating,  to  be  used.  Of  the  newer 
remedies,  probably  albargin,  in  the  strength  of  i :  5000,  or  mercury 
oxycyanid  solution,  i :  5000  or  i :  2000,  will  give  good  results. 

In  certain  cases  of  chronic  cystitis  the  following  combination 
has  been  recommended  for  bladder  irrigations:  Tincture  of  iodin, 
one  part,  potassium  iodid,  one  part,  extract  of  belladonna,  one 
part,  water,  300  parts;  or,  if  preferred,  the  belladonna  may  be 
omitted,  and  the  amount  of  tincture  of  iodin  be  increased  up  to 
two  or  three  parts. 

Potassium  permanganate  in  very  weak  solutions  is  also  useful. 

A  large  number  of  cases  of  cystitis  of  the  chronic  type  may  be 
divided  into  two  classes:  (i)  those  with  overdistended  bladder; 
(2)  those  with  contracted  bladder.  Overdistention  is  the  most 
common  cause  of  bladder  disease.  In  such  cases,  if  the  mucous 
membrane  is,  in  addition,  chronically  inflamed,  a  large  quantity 
of  fluid  may  be  used  in  irrigation  without  giving  rise  to  pain. 
These  cases  of  overdistention  with  cystitis  are  often  associated 
with  enlarged  prostate  or  urethral  stricture.  The  other  class, 
those  with  a  contracted  bladder,  are  usually  cases  of  pure  cys- 
titis. In  these,  there  may  be  no  urethral  lesion  or  prostatic 
obstruction.  When  irrigations  are  used  in  such  cases  care  must 
be  observed  that  too  large  an  amount  of  fluid  is  not  used.  Some- 
times the  bladders  of  such  patients  retain  with  comfort  only 
from  two  to  four  ounces  of  either  urine  or  any  irrigating  fluid. 
Although  not  to  be  recommended  for  routine  procedure,  good 
results  have  been  obtained  in  such  cases  by  irrigations,  say, 
of  from  two  to  four  ounces  of  weak  silver  nitrate  solution,  in- 
creasing the  amount  of  each  irrigation  by  60  to  90  drops  over 
the  preceding  one.  The  frequenc}^  with  which  syphilis  is  the 
cause  of  chronic  cystitis  of  the  second  type — that  with  a  contracted 


CYSTITIS  361 

bladder — should  be  borne  in  mind,  and  it  is  not  amiss  in  these 
cases  to  try  the  effects  of  mixed  treatment. 

In  non-tubercular  cases,  when  other,  measures  fail  to  bring 
rehef,  a  perineal  section  may  be  made,  a  tube  introduced,  and  the 
bladder  allowed  to  drain  for  a  week ;  thus  affording  rest  to  the  blad- 
der-wall and  diminishing  the  congestion  of  the  mucous  membrane. 
Continuous  irrigation  of  the  bladder  for  a  few  days  with  an  unir- 
ritating  solution,  appHed  through  a  double-current  catheter  passed 
through  a  suprapubic  opening  has  shown  good  results  as  a  method 
of  treatment  in  certain  cases  of  severe  cystitis.  We  think  this 
procedure  may  in  the  future  occasionally  prove  a  helpful  one. 

Tubercular  Cystitis. — ^Tubercular  cystitis  almost  never  occurs 
as  a  primary  disease,  but  results  as  an  extension  downward  of  the 
infection  from  a  tuberculosis  of  the  kidney,  or  it  occurs  as  an  as- 
cending infection  from  portions  of  the  tract  lower  down,  such 
as  from  the  urethra  or  prostate  {vide  supra).  In  its  late  stages 
it  is  diagnosed  with  comparative  ease,  and  is  accompanied  by 
such  symptoms  as  painful  and  frequent  micturition,  pus  in 
the  urine,  and  more  or  less  pain  over  the  bladder  region.  In 
the  earlier  stages  the  diagnosis  is  made  with  more  difficulty, 
for  there  may  be  only  a  slight  amount  of  burning  on  urination, 
and  the  urine  may  show  so  little  pus  as  to  appear  only  on  micro- 
scopic examination.  In  patients  with  pulmonary  tuberculosis, 
however,  even  such  mild  urinary  symptoms  should  lead  to  a 
suspicion  of  tubercular  cystitis,  particularly  if  there  has  been 
no  history  of  previous  urethral  infection.  Occasionally  a  his- 
tory of  repeated  urethral  infections  and  of  many  forms  of  treat- 
ment having  been  tried  will  be  given,  extending  over  a  period 
of  many  months  or  years,  with  a  gradually  decreasing  reac- 
tion to  treatment,  either  local  or  general.  These  symptoms, 
if  associated  with  marked  physical  depression,  even  if  there 
is  no  evidence  of  pulmonary  tuberculosis,  should  arouse  a  suspi- 
cion in  the  mind  of  the  observer  of  beginning  tuberculosis,  either 
primarily  or  secondarily  associated  with  the  bladder.  Those  cases 
of  cystitis  that  react  poorly  to  almost  all  ordinary  forms  of  treat- 
ment, either  general  or  local,  have  not  infrequently  a  tuberculous 
element,  either  pure  or  mingled  with  some  other  infection,  such 
as  gonorrhea.     Statistical  investigation  tends  to  show  that  gonor- 


362  DIAGNOSIS   AND   TREATMENT    OF    BLADDER    DISEASES 

rheal  infection  is  one  of  the  most  frequent  predisposing  causes  of 
tubercular  infection. 

By  means  of  an  air  cystoscope  ulcerations  may  be  painted; 
one  of  the  writers'  associates  recently  applied  phenol  and  iodin 
through  an  air  cystosocpe  to  vesical  ulcers  of  a  tubercular  char- 
acter, but  with  negative  results.  It  is  to  be  hoped  that  in  the 
future  increased  experience  of  surgeons  with  the  effect  of  the 
direct  application  of  local  remedies  will  be  productive  of  good 
results. 

Even  in  cases  of  contracted  bladder,  if  the  bladder  will  hold  1 50 
c.c,  which  is  not  enough,  ordinarily,  to  permit  ureter  catheteriza- 
tion, cystoscopy  may  still  be  employed. 

A  rough  but  sometimes  helpful  method  of  diagnosing  tubercu- 
losis of  the  bladder  is  that  of  observing  whether  or  not  the  bladder 
is  intolerant  to  irrigations  of  silver  nitrate  of  the  weakest  character 
even  of  a  strength  of  i  :  10,000.  Many  observers  have  noticed 
that  in  tubercular  cystitis  silver  nitrate  applications  are  badly 
borne.  This  intolerance  to  silver  nitrate,  to  be  sure,  is  not  found 
wholly  in  the  tubercular;  those  patients  of  neurotic  tendencies 
sometimes  show  marked  intolerance  to  the  drug,  and  occasionally 
a  constitutional  idiosyncrasy  against  it  exists.  Many  foreign  as 
well  as  American  writers  have  recommended  irrigations  of  silver 
nitrate  in  strengths  of  from  i  :  500  to  i  :  50;  this  is  too  strong. 
For  irrigating  either  the  bladder  or  the  deep  urethra  in  tubercular 
or  non-tubercular  cases  it  is  seldom  advisable  to  use  stronger 
irrigations  than  i  :  5000.  Locally,  for  irrigating  purposes,  solu- 
tions of  mercury  bichlorid  i  :  10,000,  may  be  used.  Iodoform 
also  seems  to  be  most  popular  among  the  local  applications 
for  the  relief  of  the  condition.  It  is  generally  used  suspended  in  oil 
or  liquid  vaselin.  In  our  hands  for  the  local  treatment  of  tubercular 
cystitis  nothing  has  given  as  good  result  as  ichthyol  in  very  weak 
solution,  of  a  strength  of  from  one  to  two  to  one  to  four  thousand 
or  even  weaker.  It  was  somewhat  by  accident  that  one  of  us 
discovered  the  value  of  these  irrigations,  which  in  the  first  case  in 
which  they  were  used  gave  more  relief  than  several  other  prepara- 
tions previously  used  in  the  form  of  irrigations  or  instillations, 
and  gave  more  relief  than  when  the  bladder  was  left  untreated 
and  general  hygienic  measures  alone  were  depended  upon.     Some 


CYSTITIS  363 

further  experience  with  its  use  in  cases  of  tubercular  cystitis 
have  tended  to  confirm  our  beHef  in  its  value,  and  we  commend 
ichthyol  to  the  profession  for  the  relief  of  this  distressing  con- 
dition. 

In  many  cases  of  tubercular  cystitis,  general  treatment,  con- 
sisting of  life  in  the  open  air,  together  with  the  internal  adminis- 
tration of  appropriate  remedies,  such  as  creasote,  can  best  be 
relied  upon  to  relieve  the  bladder  condition. 

One  of  the  great  difficulties  that  confronts  the  practitioner  in 
treating  tuberculosis  of  the  bladder  is  to  decide  whether  a  given 
tubercular  ulceration  is  due  to  a  tubercular  kidney  or  not,  as 
the  existence  of  the  latter  may  often  be  suspected  in  these 
cases  when  it  cannot  be  clearly  demonstrated  to  be  present. 
As  the  investigations  of  the  whole  matter  of  tuberculosis  of 
the  genito-urinary  system  are  carried  on  with  more  thorough- 
ness, tuberculosis  of  the  kidney  is  found  with  increasing  fre- 
quency. 

Tubercle  bacilli  are  found,  according  to  Joseph  Walsh,  in 
75  per  cent,  of  the  urines  of  fatal  cases  of  pulmonary  tuber- 
culosis. 

Since  tuberculosis  of  the  kidney  is  present  in  the  vast  majority 
of  cases  of  tuberculosis  of  the  bladder,  and  since  in  most  cases 
of  renal  tuberculosis  the  infection  is  most  marked  in  one  kid- 
ney, the  question  arises,  should  the  most  diseased  kidney  be 
enucleated  in  the  hope  that  this  step  will  aid  in  the  cure  of  the 
cystic  tuberculosis.  Apparently  removal  of  the  kidney  aids 
in  the  cure  of  the  cystitis  in  quite  a  proportion  of  cases,  par- 
ticularly if  associated  with  the  usual  methods  of  general  tuber- 
cular treatment.  In  all  cases  the  general  system,  as  a  whole, 
should  be  fortified  as  much  as  possible  by  a  large  food-supply 
and  the  greatest  amount  of  fresh  air  obtainable.  Urinary  anti- 
septics, such  as  urotropin  and  salol,  may  be  used,  nor  in  spite 
of  the  fact  that  the  kidney  is  known  to  be  diseased  should  local 
treatment  of  the  bladder  be  entirely  neglected,  but,  realizing  that 
the  bladder  is  ulcerated,  greater  care  than  ever  should  be  taken 
in  the  introduction  of  all  instruments.  All  local  measures  used 
should  first  be  tentatively  Assayed,  and  modified  as  circumstances 
seem  to  indicate.     In  irrigation  small  quantities  of  fluid  should 


364         DIAGNOSIS    AND   TREATMENT   OF    BLADDER    DISEASES 

be  used,  as  the  bladder  is  frequently  contracted — one  should 
commence  with  not  over  four  ounces. 

Bazy  advocates  that,  in  cases  where  some  mild  preliminary 
local  irrigation  has  been  used,  the  bladder  be  emptied  and  the  fol- 
lowing remedy  injected: 

Iodoform   (pulverized) 1   gram 

Vaselin  (liquid  sterilized) 20  grams. 

He  recommends  that  the  patient  refrain  from  micturating  as 
long  as  possible  after  the  injection,  and  that  urination  be  sus- 
pended on  the  first  appearance  of  oil  in  the  urine.  In  other  words, 
the  patient  should  not  completely  empty  the  bladder.  His  theory 
is  that  the  iodoform  will  sink  to  the  bottom  of  the  bladder,  where 
ulcers  are  most  likely  to  be  located,  will  serve  as  a  coating  for 
them,  and,  if  the  bladder  is  not  completely  emptied  on  urination, 
such  a  coating  may  remain  for  several  days.  Some  patients 
retain  a  portion  of  the  vaselin  for  from  three  to  fifteen  days,  at 
the  end  of  which  time  another  similar  application  may  be  made. 
Iodoform  may  also  be  administered  in  the  following  combination : 

Iodoform 1  gram 

Liquid  guaiacol 5  grams 

Sterilized  liquid  vaselin 100  grams. 

If  desired,  the  quantity  of  iodoform  in  such  solutions  may  be 
increased  four  or  five  times.  The  guaiacol  may  be  used  alone — 
5  parts  dissolved  in  100  parts  of  oil.  Gomerol,  a  substance  some- 
what resembling  guaiacol,  and  obtainable  either  pure  or  in  a  10 
per  cent,  oil  mixture,  has  been  recommended  in  the  treatment  of 
tuberculosis;  it  is  given  either  internally  or  applied  locally  by 
means  of  10  per  cent,  instillations  of  the  drug  suspended  in  oil; 
it  has  also  been  used  in  the  form  of  irrigations  (i  :  500)  for  the 
relief  of  tubercular  cystitis.  From  experiments  carried  on  by 
the  writers  they  conclude  that  the  drug  is  comparatively  harm- 
less, and  although  they  are  not  enthusiastic  over  its  use,  they 
consider  it  worthy  of  further  investigation. 

STONE  IN  THE  BLADDER 
The  frequency  with  which  stones  occur  in  the  bladder  apparently 
depends  to  a  great  extent  on  climate.     In  the  writers'  experience, 


STONE    IN   THE    BLADDER  365 

cases  of  vesical  calculi  are  not  numerous  in  New  York  city  or  its 
immediate  vicinity.  In  some  European  countries,  especially  in 
England,  and  in  India  they  are  quite  prevalent. 

The  symptoms  of  stone  in  the  bladder  resemble  closely  those 
of  chronic  cystitis,  with  or  without  enlargement  of  the  prostate, 
a  condition  that  is  often  associated  with  the  presence  of  vesical 
calculi.  The  patients  generally  complain  of  some  disturbance  of 
micturition,  which  is  more  noticeable  during  the  day  than  at  night, 


Fig.  133. — Cystic  calculi  (from  the  B.  Farquhar  Curtis  collection  in  the  Museum  of  Carnegie 
Laboratory):  a,  Calculus  mostly  composed  of  ammonio-magnesium  phosphate,  weight  20  Gm. 
(reduced  one-half);  b,  stone  largely  composed  of  calcium  oxalate,  weight  4.8  Gm.  (reduced 
one-half);  c,  fragments  of  calculi  formed  about  a  silk  suture  (c')  left  in  the  bladder  after  a 
suprapubic  cystotomy;  rf,  uric  acid  calculus  (natural  size);  ;»,  mixed  calculus,  largely  phos- 
phatic,  weight  30  Gm.  (reduced  one-half);  y,  small,  hard  oxalate  calculus  (natural  size);  g, 
mixed  calculus,  largely  alkaline  phosphates,  weight   13  Gm.  (one-half  natural  size). 

and  is  apt  to  be  augmented  by  exercise.  Riding  over  a  rough 
road  or  any  act  that  tends  to  cause  congestion  at  the  base  of  the 
bladder  aggravates  this  symptom.  The  urine  is  generally  turbid, 
and  indications  of  catarrhal  or  purulent  cystitis  are  present. 
A  useful  diagnostic  point  is  that  occasionally,  while  the  stream 
of  urine  is  quite  strong,  it  is  suddenly  completely  checked,  with- 
out any  dribbhng  taking  place,  as  generally  occurs  when  the 
urinary  volume  is  diminished  owing  to  prostatic  hypertrophy. 
After  a  time  the  patients  are  again  able  to  urinate  as  freely  as  ever. 


366  DIAGNOSIS    AND    TREATMENT    OF    BLADDER    DISEASES 

This  interference  with  urination  is  due  to  the  stone  faUing  up 
against  the  opening  of  the  urethra  into  the  bladder. 

In  examining  for  suspected  stone,  and  also  to  get  an  insight 
as  to  the  size  and  condition  of  the  bladder,  and  to  learn  the 
general  feel  of  the  bladder  (the  bladders  of  old  persons,  as  is 
well  known,  often  present  ridges  that  are  easily  distinguish- 
able), the  Thompson  searcher  (Fig.  13)  is  the  instrument  gen- 
erally used.  In  the  absence  of  a  Thompson  searcher  a  medium- 
sized  steel  sound  may  be  employed.  Dr.  Chismore  has  modi- 
fied the  Thompson  searcher  so  that  it  represents  an  instrument 
of  the  same  curve  and  length  as  his  lithotrite. 

After  the  bladder  has  been  emptied,  several  ounces  of  fluid  are 
injected  into  it  through  a. catheter;  or,  the  searcher  being  hollow, 
the  fluid  may,  if  it  is  preferred,  be  injected  through  the  nozle  of 
the  syringe  placed  in  the  opening  at  its  upper  end;  the  searcher 
is  introduced  into  the  bladder,  and  pushed  to  the  back  wall,  care- 
fully avoiding  inflicting  injury,  its  beak  pointing  upward;  then, 
by  means  of  its  handle,  the  searcher  is  revolved  a  little  from  one 
side  to  the  other,  and  is  gradually  withdrawn  until  it  reaches  the 
urethral  opening  into  the  bladder.  Now,  the  searcher  being 
revolved  a  Uttle  on  its  passage  from  the  back  to  the  front  wall 
of  the  bladder,  it  will  strike  the  bladder- wall  first  on  one  side, 
and  then  on  the  other,  at  the  urethral  orifice.  The  searcher  is 
divided  off  into  inches  and  their  fractions,  and  there  is  a  small 
sliding  scale  that  moves  up  and  down  on  the  shaft  of  the  searcher. 
It  should  be  noticed,  as  it  strikes  the  anterior  wall  of  the  bladder, 
being  revolved  from  side  to  side,  whether  it  meets  with  an  obstruc- 
tion on  one  side  sooner  than  it  does  on  the  other.  If  it  does,  this 
indicates  generally  a  lateral  enlargement  of  the  prostate  on  the 
side  that  shows  the  obstruction  first.  After  this  procedure  has 
been  completed,  the  searcher  may  be  pushed  to  the  back  wall  of 
the  bladder  again  and  completely  rotated,  so  that  its  beak  points 
downward  toward  the  base  of  the  bladder.  It  may  then  be 
brought  forward  and  rotated  from  side  to  side,  as  was  previously 
done,  except  that  this  time  the  beak  points  downward.  When 
it  approaches  the  urethral  orifice,  it  will  naturally  meet  with  an 
obstruction  to  its  entire  removal,  for  the  reason  that  its  beak  is 
lower  than  the  urethral  orifice;   if,  however,  there  is  much  third 


STONE    IN   THE    BLADDER  367 

lobe  enlargement  of  the  prostate,  a  practised  hand  may  be  able 
to  detect  this  from  the  angle  that  the  searcher  assumes  or  from 
the  feel  of  the  obstruction  as  the  searcher  strikes  it.  If  a  stone  in 
the  bladder  is  present,  it  will  very  Hkely  be  encountered  with  the 
end  of  the  searcher  on  its  journeys  back  and  forth,  as  described. 
If  the  searcher  strikes  a  stone,  a  characteristic  feel  will  be  im- 
parted to  the  hand  and  sometimes  a  cHck  will  be  heard.  When 
this  is  noticed,  the  angle  should  be  carefully  observed,  and 
also,  by  means  of  the  measuring  scale,  the  distance  should  be 
carefully  gaged,  and  the  searcher  withdrawn  and  a  Chismore 
lithotrite  introduced,  when,  if  it  is  placed  at  exactly  the  same 
angle  and  at  the  same  distance  as  shown  by  the  measuring  scale, 
the  stone  should  be  reached.  In  using  the  searcher  for  detect- 
ing the  presence  of  prostatic  enlargement  it  is  a  good  plan,  after 
the  obstruction  has  been  encormtered,  to  introduce  a  finger 
of  one  hand  into  the  rectum,  the  other  hand  holding  the  searcher 
in  the  bladder ;  the  distance  between  the  searcher  and  the  finger 
may  then  be  estimated.  The  same  procedure  may  be  followed 
when  the  searcher  strikes  a  stone,  but  care  should  be  observed 
not  to  move  the  stone  too  much  if  it  is  to  be  crushed  immediately, 
or  it  will  get  out  of  position.  It  would  hardly  be  necessary  to 
describe  this  simple  procedure  in  such  detail  were  it  not  for  the 
fact  that  it  lends  valuable  aid  and  is  a  method  that,  the  wTiters 
find,  is  very  often  neglected  by  the  general  practitioner  and  by 
the  members  of  house-staffs  in  hospitals.  If  there  is  any  doubt  in 
the  mind  of  the  surgeon  as  to  the  condition  of  the  bladder  and  as 
to  the  presence  or  absence  of  stone  (further  than  is  furnished  by 
the  searcher),  a  small  exploring  cystoscope  should  be  introduced 
and  the  bladder-walls  examined  with  the  aid  of  electric  light. 

As  is  well  known,  in  cases  of  third  lobe  prostatic  enlargements 
a  pocket-Hke  sacculation  is  formed  at  the  base  of  the  bladder, 
beneath  the  projecting  third  lobe;  this  pocket  is  often  a  favorite 
site  for  the  lodgment  of  a  calculus.  Once  a  stone  has  become 
lodged  here,  it  is  somewhat  harder  to  reach  with  the  lithotrite, 
and,  if  the  instrument  is  reversed,  it  is  possible  for  a  careless 
operator  to  grasp  the  third  lobe  between  the  two  jaws  of  the 
instrument  and,  by  crushing,  do  an  immense  amount  of  damage. 
Even  if  an  enlarged  third   lobe  is  not  present,  the  rectovesical 


368 


DIAGNOSIS   AND    TREATMENT    OF    BLADDER    DISEASES 


fold  may  project  up  into  the  bladder  at  the  base, 
making  an  apparent  sacculation  that  may  also,  if 
care  is  not  used,  be  grasped  between  the  jaws  of 
the  reversed  Hthotrite  and  damaged.  It  is  better 
in  these  cases  first  to  ascertain  the  effect  of  throw- 
ing a  current  of  fluid  into  the  bladder,  for  by  this 
means  the  stone  may  be  thrown  into  the  jaws  of 
the  lithotrite,  and  careless  manipulation  with  the 
beak  of  the  instrument  reversed  thus  be  obviated. 


Fig.      134-  —  Bige- 
low's  lithotrite. 


Fig.  135. — Bigelow's  evacuator. 
LiTHOLAPAXY 

The  operation  of  litholapaxy,  or  that  of  crush- 
ing and  evacuating  stones  in  the  bladder  by 
means  of  instruments  devised  for  the  purpose, 
has  been  employed  since  the  early  part  of  the 
nineteenth  century.  A  great  many  modifications, 
both  in  technic  and  in  the  instruments  themselves, 
have  been  made  from  time  to  time.  Space  will 
not  permit  of  a  detailed  historic  account  of  the 
development  of  this  interesting  operation.  It 
may  be  briefly  stated,  however,  that  the  original 
instruments  for  crushing  stone  were  devised  by 
French  surgeons.  An  important  modification 
was  the  invention,  by  the  late  Dr.  John  Bigelow, 
of  Boston,  of  an  evacuator,  which,  by  aspiration, 


STONE    IN   THE    BLADDER 


369 


removes  the  fragment  of  the  stone.  Later  on  an  important  ad- 
vance was  made  by  Dr.  Joseph  D.  Bryant,  of  New  York,  who 
devised  an  instrument  that  served  both  as  a  crusher  and  an 
evacuator.  In  this  the  female  blade  of  the 
crusher  encircled  a  catheter,  so  that  the 
bulb  of  the  evacuator  could  be  attached 
to  the  handle  of  the  crusher,  and  fluid  re- 
moved from  the  bladder  through  a  hole 
in  the  female  blade,  or  forced  into  the 
bladder  by  means  of  the  aspirating  bulb 
through  the  same  blade,  thereby  creating 
a  current  in  the  bladder  that  washed  the 
stone  or  fragments  of  stone  in  between  the 
jaws  of  the  crusher.  The  late  Dr.  George 
Chismore,  of  San  Francisco,  a  recognized 
authority  on  operations  for  the  removal 
of  vesical  calculi,  performed  this  crushing 
operation  on  154  cases  of  stone  in  the 
bladder.  He  kindly  placed  at  the  writers' 
disposal  not  only  his  detailed  description 
of  the  valuable  modifications  of  the  opera- 
tion as  devised  by  him,  but  also  his  history 
book  and  the  manuscript  of  a  forthcoming 
treatise  on  the  subject,  written  by  him  and 
his  associate,  Dr.  Edward  Giles  McCormick, 
of  the  same  city.  From  personal  experi- 
ence in  the  past  the  writers  prefer  to  effect 
removal  of  a  stone  through  a  suprapubic 
opening  rather  than  to  attempt  to  crush  it ; 
Dr.  Chismore' s  modifications  of  previous 
instruments  seem  so  ingenious,  however, 
and  his  results,  which  are  fairly  stated, 
have  been  so  good,  that  it  has  convinced 
us  that  there  may  still  be  a  fruitful  field 
for  the  operation  of  litholapaxy. 

Dr.  Chismore's  first  modification  consisted  in  the  making  of  a 
catheter  in  the  male  blade.     This  catheter  has  a  large  eye,  so  that 
24 


Fig.  136. — Chismore's  evacuat- 
ing lithotrite. 


37°         DIAGNOSIS   AND   TREATMENT   OF   BLADDER    DISEASES 

good-sized  fragments  can  be  sucked  through  when  the  evacuator 
bulb  is  attached  to  the  handle  of  the  crusher;  the  second  advan- 
tage of  this  modification  is  that  a  stream  of  water  can  be  forced 
through  the  catheter  in  the  male  blade,  thus  sending  a  current 
of  water  into  the  bladder,  which  loosens  up  stones,  and,  through 
the  force  and  direction  of  the  current,  brings  them  into  the  jaws 


Fig.  137. — ^The  Chismore  bladder  evacuator  and  obturator. 


of  the  crusher  and  so  sometimes  prevents  the  necessity  of  turning 
the  crusher  around  with  its  beak  pointing  toward  the  base  of  the 
bladder.  Dr.  Chismore  has  also  invented  a  hammer  for  use  when 
hard  fragrhents  of  stone  are  caught  between  the  blades  of  the 
crusher,  and  cannot  be  crushed  by  the  hand- screw  on  the  end  of  the 
instrument  or  by  an  assistant  using 

a  ratchet  and  pinion  on  the  side  of  -,..s«s»^^ 

the  instrument.  This  hammer  is 
attached  to  the  crusher  while  in 
position,  and  works  on  the  prin- 
ciple of  a  pneumatic  drill.  It  re- 
sembles in  action  a  hammer  such 
as  dentists  use  in  filling  teeth. 

Technic. — The  Chismore  litho- 
trite  is  prepared  for  use  by  lubri- 
cating the  male  blade  freely  with 
a  stiff  ointment  of  lanolin  to  which 
ten  grains  to  the  ounce  of  boric 
acid  has  been  added,  working  it 
back  and  forth  until  the  lubricant  is  thoroughly  distributed  be- 


Fig.  138. — Curved  and  straight  evacu- 
ating tubes  for  removing  fragnients  oi 
crushed  stone. 


STONie    IN   THE    BIvADDER  371 

tween  the  male  and  female  shafts.  This  serves  as  a  packing  to 
prevent  the  ingress  of  air  and  the  egress  of  fluid  while  aspirating. 
This  point  is  important  and  must  not  be  neglected,  for  if  it  is, 
fluid  will  escape  freely  from  the  bladder  between  the  shafts  of  the 
male  and  female  blade  when  the  aspirator  is  compressed,  and 
air  will  rush  in  when  the  bulb  is  relaxed,  thus  rendering  the  pro- 
cedure a  partial  or  even  a  total  failure.  Two  aspirators  should  be 
on  hand,  from  which  the  air  should  be  withdrawn  by  a  syringe. 
(When  seeking  a  stone  with  a  searcher,  if  the  stone  is  found,  an 
attempt  should  be  made  to  find  its  farthest  border,  and,  having 
found  it,  the  index  on  the  searcher  at  the  meatus  should  be  set, 
and  an  effort  made  to  approximate  its  size  by  withdrawing  the 
searcher  until  its  nearest  border  is  felt.  Note  the  angle  that  the 
shaft  of  the  searcher  makes  with  the  axis  of  the  body.  The  stones 
are  generally  found,  according  to  Chismore,  in  the  region  of  the 
base  of  the  bladder,  to  one  side  of  the  median  line — most  fre- 
quently the  right.) 

The  stone  having  been  discovered  and  located,  ordinarily  an 
attempt  should  be  made  to  crush  it  immediately. 

One  and  one-half  to  three  ounce-s  of  a  warm  i  per  cent,  solution 
of  cocain  should  be  injected  into  the  bladder  through  the  searcher 
or  through  a  catheter.  Chismore  recommends  that  the  opera- 
tion be  done  with  the  bladder  as  nearly  empty  as  is  convenient, 
and  considers  that  nothing  but  harm  follows  the  strenuous  use  of 
antiseptic  solutions  employed  for  the  purpose  of  rendering  the 
bladder-wall  as  clean  as  possible. 

In  about  five  minutes  the  bladder  should  be  anesthetized; 
then  the  lithotrite  may  be  introduced,  great  care  being  taken 
to  overcome  spasm  and  to  proceed  with  gentleness  in  pass- 
ing the  triangular  Hgament.  Carry  the  instrument  to  the  further 
end  of  the  stone,  and  then  go  still  a  Uttle  further.  Open  the  shaft 
to  a  width  that  will  accommodate  the  stone  if  the  size  is  known. 
Deflect  the  beak  in  the  direction  in  which  the  stone  is  known 
to  be,  seeing  that  the  angle  is  the  same  as  was  the  angle  of  the 
searcher,  and  close  the  jaws  of  the  instrument.  If  the  stone  is  not 
grasped  the  first  time,  another  effort  should  be  made.  If  this 
does  not  succeed,  gently  push  the  bladder  up  with  the  female 


37-  DIAGNOSIS    AND    TREATMENT    OF^    BLADDER    DISEASES 

blade  and  depress  the  jaws  by  elevating  the  handle  of  the  instru- 
ment,  thus  giving  the  bladder  a  V  shape  with  the  instrument  in 
the  angle  of  the  V.  Squeeze  in  an  ounce  or  two  of  fluid  by  coup- 
ling on  the  aspirator,  then  sharply  relax  the  aspirator  bulb  so 
that  the  fluid  will  be  drawn  out  again,  for  it  is  possible  that  in 
this  way  the  stone  will  be  drawn  into  the  jaws.  It  may  be  neces- 
sary to  repeat  this  maneuver  over  and  over,  varying  the  angle  of 
the  shaft,  or  perhaps  reversing  the  jaws,  which  should  be  very 
frequently  closed  in  order  to  determine  whether  the  stone  has 
been  seized.  When  the  stone  has  been  secured,  manipulate  it 
slightly,  so  as  to  ascertain  that  the  bladder-walls  have  not  been 
grasped  as  well. 

There  are  three  methods  of  crushing  a  stone:  One  is  by  the 
use  of  the  hand-cap;  another  is  by  means  of  the  ratchet  and 
pinion ;  and  a  third  is  accomplished  by  the  aid  of  the  hammer. 
The  Hne  of  procedure  is  as  follows:  First  try  the  hand- 
cap;  when  that  fails,  let  an  assistant  use  the  pinion;  this  fail- 
ing, let  the  assistant  hold  the  stone  as  firmly  as  possible  with 
the  pinion  while  the  operator  fixes  the  hammer;  holding  this 
in  his  right  hand,  he  makes  firm  pressure  on  a  Hne  with  the 
shaft  of  the  lithotrite — this  pushes  the  piston  slightly  inward  and 
sets  it.  Then,  with  the  first  and  second  fingers  of  the  same  hand, 
he  brings  the  lugs  sharply  home;  this  releases  the  hammer  and 
delivers  the  stroke;  the  left  hand,  in  the  meantime,  holding  the 
female  blade  of  the  Hthotrite,  controls  the  position  of  the  jaws 
within  the  bladder  and  also  furnishes  the  counterresistance  to 
the  force  of  the  hand-cap,  pinion,  or  hammer.  The  stone  being 
crushed,  the  aspirator  may  be  used  again  to  remove  the  fragments, 
or  a  larger  tube,  to  which  the  aspirator  may  be  attached,  may  be 
introduced  for  evacuating  the  material. 

If  there  is  much  pain,  the  cocain  solution  may  be  released  and  a 
fresh  one  injected.  When  the  operation  is  over,  the  cocain 
solution  should  be  washed  out  with  a  small  quantity  of  boric  acid. 
The  after-treatment  is  simple.  The  small  fragments  that  remain 
after  thorough  aspiration  will  generally  pass  out  of  the  urethra 
spontaneously,  but  if  there  are  indications  that  large  fragments 
remain,  after  a  few  days  a  litholapaxy  tube  may  be  introduced 
to  remove  them. 


STONE    IN   THE    BLADDER  373 

In  elderly  and  feeble  patients  and  in  those  with  enlarged  pros- 
tate, particularly  enlargement  of  the  third  lobe,  even  greater  care 
and  gentleness  are  necessary,  and  several  attempts  may  be  needed 
before  the  stone  is  finally  reached.  In  such  cases  the  stones  are 
generally  lodged  in  the  pocket  behind  the  third  lobe,  and  if  the 
jaws  of  the  instrument  are  reversed  in  order  to  reach  them,  care 
must  be  used,  as  was  previously  directed,  lest  the  third  lobe  be 
grasped  between  the  jaws  of  the  instrument  or  a  fold  of  the 
rectovesical  membrane  be  crushed.  It  is  a  good  plan,  after 
the  stone  has  been  seized  by  the  lithotrite,  to  rotate  the  instru- 
ment slightly  to  be  certain  that  no  mucous  membrane  has  been 
seized. 

After  the  stone  has  been  crushed,  if  fragments  get  in  behind 
the  third  lobe,  they  are  very  often,  after  a  few  days,  washed  out. 
Here,  as  in  many  conditions  of  the  genito-urinary  tract  of  similar 
nature,  when  the  patients  are  so  much  enfeebled  that  heroic  meas- 
ures cannot  safely  be  undertaken,  time  is  an  important  factor. 
As  regards  the  results  that  may  be  expected  from  the  removal  of 
vesical  calculi,  these  are  dependent  on  the  individual  case.  It  is 
not  to  be  expected  that  in  an  old  man  with  a  large  prostate,  chronic 
cystitis  and  incontinence  of  urine  would  entirely  disappear  after 
the  removal  of  a  stone,  although  a  large  measure  of  relief  will 
generally  follow.  When,  however,  no  complications  exist,  a 
complete  cure  will  naturally  be  expected  to  follow.  It  is  the 
writers'  belief  that  in  New  York  and  its  vicinity  the  treatment 
of  stone  in  the  bladder  by  litholapaxy  has  not  received  sufficient 
attention  in  the  past,  the  tendency,  in  almost  all  cases  of  vesical 
calculi,  to  perform  suprapubic  cystotomy  being  on  the  increase. 
It  is  difficult,  however,  to  formulate  a  series  of  rules  that  will  be 
applicable  to  all  cases.  Suprapubic  cystotomy,  when  good  after- 
nursing  can  be  assured  and  the  patient  is  in  a  fair  degree  of  health, 
will  probably,  with  many  surgeons,  be  the  operation  of  choice, 
since  under  such  circumstances  the  danger  of  a  suprapubic  fistula 
forming  is  reduced  to  a  minimum,  and  the  operator  can  be  certain 
that  the  stone  has  been  entirely  removed.  On  the  other  hand, 
in  dealing  with  patients  with  stone  in  the  bladder  who  are  unwill- 
ing to  submit  to  a  cutting  operation,  who  are  aged  or  very  infirm, 


374  DIAGNOSIS   AND    TREATMENT    OF   BLADDER    DISEASES 

or  when  it  is  not  possible  to  obtain  good  after-treatment,  litho- 
lapaxy  is  to  be  preferred. 

Remarks  on  the  Removal  of  Vesical  Calculi. — In  cases  of  stric- 
ture of  the  urethra  that  will  not  easily  permit  of  the  introduction 
of  the  lithotrite,  the  stricture  should  be  well  dilated  before  any 
attempt  is  made  to  do  Htholapaxy.  In  elderly  persons  a  stone  in 
the  bladder  will  often  be  found  associated  with  enlarged  prostate, 
and  it  is  well,  therefore,  when  doing  a  prostatectomy,  to  examine 
the  bladder  for  stone,  and  if  one  is  found,  to  remove  it  through  the 
opening  used  for  prostatic  enucleation.  In  two  cases  seen  by  the 
writers  it  was  found  difficult  to  remove  the  stone  through  the 
opening  made  for  a  perineal  prostatectomy,  and  a  suprapubic 
opening  was  also  required. 

Encysted  stones  may  frequently  be  detected  by  the  searcher, 
or  may  be  seen  by  the  cystoscope,  but  the  surgeon  will  find  that 
he  is  unable  to  remove  them.  In  attempting  their  removal  a 
suprapubic  cystotomy  is  the  operation  to  be  preferred.  Chis- 
more  has  found  that  oxalate  of  lime  stones  are  those  most  fre- 
quently encountered;  next  in  frequency  come  the  phosphatic 
calculi,  whereas  the  uric-acid  formations  are  least  likely  to  occur. 
Occasionally  stones  form  very  rapidly,  large  quantities  of  gravel 
coming  down  from  the  kidney  acting  as  a  nucleus.  Sometimes 
the  crushing  must  be  repeated  every  two  or  three  months,  or  the 
stones  may  not  reform  for  several  years.  Dr.  Chismore  operated 
fifteen  times  on  one  man.  The  bladder  should  be  inspected  very 
carefully  about  a  month  after  a  stone  has  been  removed,  and,  if 
possible,  the  patient  should  be  kept  under  observation  and  be 
seen  several  times  a  year. 

Bladder  Puncture. — This  is  occasionally  done  for  temporary 
emptying  of  the  bladder,  by  means  of  an  aspirating  needle  or  a 
trocar.  It  is  generally  used  as  an  expedient  for  temporary  relief 
of  distention  preceding  some  operation  which  may  have  to  be 
temporarily  delayed.  The  puncture  should  be  made  as  near  the 
pubes  as  possible,  so  as  to  avoid  wounding  the  peritoneum.  It 
should  be  made  as  exactly  as  possible  in  the  median  Hue  of  the 
abdomen,  so  as  to  avoid  wounding  the  veins  on  the  outer  surface 
of  the  bladder.  Every  possible  precaution  should  be  taken  as 
to  the  sterilization  of  instrument  and  cleanliness  of  the  field  of 


CURETTAGE  OF  THE  BLADDER  375 

operation.  In  doing  retrograde  catheterization,  occasional  success- 
ful attempts  have  been  made,  through  the  use  of  a  trocar,  to  per- 
form retrograde  catheterization.  The  operation,  however,  is 
not  one  that  ordinarily  commends  itself  to  the  surgeon.  In  the 
past  this  operation  was  most  often  performed  for  retention  of 
urine  due  to  obstruction,  such  as  that  caused  by  an  enlarged 
prostate.  The  trocar,  or  aspirating  needle,  should  be  made  to 
penetrate  for  a  distance  of  one  and  one-half  to  two  and  one-half 
inches  from  the  surface  of  the  abdomen,  according  to  the  amount 
of  fat  present  in  the  abdominal  walls.  It  is  safer,  in  order  to  avoid 
wounding  the  peritoneum,  to  make  a  very  small  preliminary  inci- 
sion immediately  above  the  pubes  down  to  the  bladder-wall  before 
making  puncture.  When  obtainable,  a  curved  instrument  should 
be  used  with  its  concavity  pointing  toward  the  pubes. 

Curettage  of  the  Bladder 

A  general  cleaning  up  of  the  walls  of  mucous  membrane  of  the 
bladder  is,  in  our  experience,  a  useful  procedure  in  cases  of  old 
chronic  cystitis,  especially  in  a  certain  type  seen  most  generally 
in  elderly  people  of  poor  general  condition,  where  the  chronic 
cystitis  seems  to  be  changing  into  a  general  malignant  growth. 
This  cleaning-up  process  should  involve  only  the  mucous  mem- 
brane of  the  bladder,  and  great  care  should  be  taken  not  to  invade 
the  muscular  coat.  It  is  best  performed  through  a  suprapubic 
opening,  with  the  bladder  well  illuminated,  through  the  use  of  a 
curette.  If  it  seems  practical,  this  curettage  should  be  aided  to 
some  extent  by  the  galvanocautery.  These  cases  in  our  experi- 
ence following  such  a  procedure  do  surprisingly  well  for  a  time,  the 
bladder  opening  healing  up,  pain  diminishing,  and  the  character 
of  the  urine  improving,  but  as  such  cases  are  generally  seen  in 
hospital  wards  and  in  patients  whose  general  condition  leaves 
much  to  be  desired,  the  prognosis  as  regards  any  long  lease  of  life 
should  be  guarded,  as  death  is  liable  to  ensue  within  a  few  months, 
if  not  primarily  due  to  the  chronic  inflammatory  condition  of 
the  bladder,  from  some  intercurrent  disease. 

It  is  somewhat  difficult  to  give  very  precise  direction  as  to  the 
best  manner  in  which  this  curettage,  if  curettage  it  can  be  called, 
should  be  performed,  as,  in  our  experience,  which  has  been  quite 


376  DIAGNOSIS   AND  TrBATMBNT   OF    BLADDER    DISEASES 

considerable  in  this  class  of  cases,  each  individual  case  differs 
somewhat  from  the  preceding.  Such  cases,  particularly  where 
they  are  met  with  in  old  thin,  cachectic  individuals,  are  very  liable 
to  have  extremely  thin  and  friable  bladder-walls,  and  while  the 
removal  of  the  diseased  tissue  to  as  great  an  extent  as  possible 
seems  to  be  attended  with  very  good  results,  great  care  and  gentle- 
ness is  required  to  prevent  punctures  of  what  little  is  left  of  the 
muscular  coat  of  the  bladder-wall.  Simply  scraping  such  growths 
off  with  the  finger  is  sometimes  all  that  should  be  attempted. 

Suprapubic  Cystotomy 

This  operation  of  opening .  the  bladder  through  the  abdom- 
inal wall  has  come  into  more  general  use  within  the  past  twentv 
years,  and,  the  writers  believe,  its  present  popularity  is  well 
merited.  It  is  now  to  a  great  extent  the  operation  chosen  for 
the  surgical  relief  of  stone  in  the  bladder,  and  it  is  very  fre- 
quently employed  when  the  prostate  is  to  be  also  attacked.  The 
difficulties  attending  the  performance  of  this  operation  have  been 
somewhat  exaggerated.  There  are,  however,  certain  practical 
objections  to  its  indiscriminate  use.  One  of  these  is  that  the 
peritoneum  may  be  wounded ;  this  objection  is  overcome  in  large 
measure,  however,  if  proper  small  catgut  sutures  are  kept  at  hand, 
and  if  the  wound  is  immediately  sutured,  for  but  little  harm  will 
result.  The  greatest  practical  objection  to  its  performance  is  the 
difficulty  with  which  the  suprapubic  wound  heals  after  the  opera- 
tion. Much  depends  on  keeping  the  edges  of  the  wound  clean; 
these  are  soiled  by  the  urine  that  is  continually  flowing  through 
the  suprapubic  opening.  In  any  given  case,  therefore,  in  which 
the  surgeon  feels  assured  that  the  patient  will  receive  the  proper 
attention  after  the  operation,  it  is  often  the  operation  of  choice. 
When  doubt  exists  as  to  the  efficiency  of  the  nurse,  or  when  it  is 
questionable  whether  or  not  the  wound  will  receive  the  proper 
attention,  some  other  method  of  entering  the  bladder  should, 
when  possible,  be  attempted.  This  operation  is  almost  never 
performed  on  the  female.  The  technic  of  the  operation  is  as 
follows : 

The  pubes  and  scrotum  having  been  shaved  and  the  operative 
toilet  having  been  carefully  made,  the  bladder  should  be  washed 


SUPRAPUBIC    CYSTOTOMY 


377 


out,  and  as  much  of  a  saturated  solution  of  boric  acid  should  be 
injected  through  a  catheter  into  the  bladder  as  the  organ  will 
comfortably  hold — usually  about  one  pint. 

After  the  bladder  has  been  filled,  a  catheter  should  be  tied  around 
the  root  of  the  penis,  to  prevent  escape  of  the  fluid.    It  not  infre- 
quently happens  that  during  an  operation  through  the  perineum 
'for  the  relief  of  prostatic  hypertrophy,  it  is  decided  to  open  the 


Fig.    139. — Suprapubic  cystotomy  (Lejars). 

bladder  from  above.  When  this  step  is  determined  upon,  it  will 
not  be  necessary  to  inject  fluid  into  the  bladder,  but  if  there  is 
sufficient  room  in  the  urethra,  an  ordinary  steel  sound  may  be 
passed  into  the  bladder,  and  the  tip  of  the  sound  be  cut  down  upon 
suprapubically.  If  for  other  reason  it  is  found  desirable  to  open 
up  the  bladder  without  filling  it,  the  same  measures  may  here 
be  adopted.  By  the  latter  method  of  performing  the  operation, 
however,  the  danger  of  wounding  the  peritoneum  is  somewhat 
increased.  The  bladder  filled,  the  head  of  the  table  should  then 
be  somewhat  lowered,  so  as  to  bring  the  operative  ground  a  little 
more  prominently  into  the  field  and  to  help  to  keep  the  peritoneal 
fold  from  the  front  of  the  bladder. 


;78         DIAGNOSIS   AND   TREATMENT   OF    BLADDER    DISEASES 


Having  placed  the  patient  in  the  proper  position,  a  straight 
incision,  about  six  inches  long,  beginning  just  below  the  upper 
border  of  the  pubic  bones  and  passing  directly  upward  in  the 
median  line,  should  be  made.  The  length  of  the  incision  through 
the  skin  will  depend  somewhat  on  the  amount  of  fat  in  the  in- 
dividual, a  fat  person  requiring  a  longer  skin  incision  than  a  thin 
one.     The  skin  is  cut  through,  and  then  the  white  line  of  the 

muscle-fibers  is  in- 
cised. At  the  lower 
part  of  the  wound  the 
small  fibers  of  the 
pyramidal  muscles 
may  be  cut  through 
or  pushed  to  one  side,' 
and  the  muscular 
aponeurosis  of  the 
underlying  muscle  cut 
through,  when  the 
yellow  prevesical  fat 
will  appear.  When 
this  is  seen,  the  blad- 
der-wall is  near  at 
hand;  it  is  well  then, 
with  the  finger  or  the 
handle  of  the  knife, 
to  press  the  fat  as 
far  as  possible  out  of  the  way.  In  cutting  through  the  tissues 
just  mentioned  as  being  surrounded  by  the  fat,  a  few  small 
vessels  may  be  severed ;  there  being  no  large  ones  in  this  region 
or  very  close  to  it.  Such  vessels  as  are  cut  through  should  be 
immediately  ligated,  thus  keeping  the  approach  to  the  bladder 
as  clean  as  possible.  Venous  bleeding,  which  is  sometimes  con- 
siderable, will  generally  cease  when  the  bladder-wall  is  cut  through. 
When  the  bladder  wall  is  approached  or  when  it  can  be  outlined 
with  the  finger,  it  is  well  to  pass  a  sharp  hook  through  what 
appears  to  be  the  wall,  keeping  as  near  as  possible  to  the  supe- 
rior border  of  the  pubes,  the  wound  through  the  skin  and  muscles 
having  been  held  open  by  retractors.     Having  hooked  the  blad- 


Fig.  140. — Suprapubic  cystotomy  (Lejars). 


SUPRAPUBIC    CYSTOTOMY 


379 


der-wall,  a  very  small  puncture  should  be  made  to  one  side  of  the 
hook,  as  near  the  pubes  as  possible;  the  escaping  fluid  will  indicate 
that  the  bladder  has  been  punctured.  Before  proceeding  further, 
examine  carefully  to  see  if  the  peritoneum  has  been  wounded.  If 
this  has  been  done,  the  peritoneum  should  be  repaired,  and  then 


Fig.  141. — Suprapubic  cystotomy.    Right  hand  incising  bladder,  left  hand  holding  hook 

(Lejars). 


pushed  as  far  as  possible  out  of  the  way.  Having  punctured  the 
bladder,  a  ligature  should  be  passed  through  the  bladder  wall  on  one 
side,  and  a  corresponding  ligature  on  the  other;  the  hook  should 
then  be  removed,  the  wound  in  the  bladder  wall  being  held  open  by 
an  assistant  pulling  on  the  ligature  on  each  side ;  the  incision  should 
be  extended  upward  as  far  as  may  be  required,  or  far  enough  to 
allow  the  introduction  of  one  or  two  fingers  into  the  opening  in 


380  DIAGNOSIS   AND   TREATMENT    OF    BLADDER    DISEASES 

order  thoroughly  to  examine  the  inner  bladder-wall.  In  perform- 
ing operations  on  the  bladder  the  writers  find  it  most  convenient 
to  have  at  hand  a  small  portable  electric  light,  about  the  size  of  a 
pea,  on  a  flexible  wire;  this  they  drop  into  the  bladder  in  order 
that  the  existing  conditions  may  be  seen  as  well  as  felt.  In 
operations  done  for  the  simple  extraction  of  a  stone,  this  procedure 
is  unnecessary,  for  the  stone  can  be  grasped  at  once.  If  desired 
the  bladder  wound  may  be  enlarged  by  placing  a  retractor  in  each 
side  of  the  wound  and  a  third  retractor  in  the  upper  end  of  the 
incision,  the  Hgatures  preventing  the  bladder  from  sinking  back 
into  the  pelvis. 


Fig.    142. — Suprapubic  cystotomy. 


First  layer  of  non-perforating  sutures  (redrawn  from. 
Albarran). 


The  bladder  having  been  opened  and  thoroughly  examined, 
and  any  wound  in  the  peritoneum  having  been  repaired,  the  im- 
portant question  to  be  next  considered  is  that  of  the  repair  of  the 


SUPRAPUBIC    CYSTOTOMY 


381 


bladder  wall.  It  is  becoming  more  and  more  the  custom,  par- 
ticularly in  Europe,  to  try  to  obtain  priman,'  union  of  the  blad- 
der wall  through  sewing  the  wall  up  immediately  following  a 
suprapubic  cystotomy,  and  trust  for  drainage  to  a  retention 
catheter  introduced  through  the  urethra.  Ordinarily,  this 
procedure  will  only  be  effective  in  a  non-infected  bladder,   and 


Fig.    143. — Suprapubic  cystotomy.     Second  layer  of  non-perforating  sutures  (redrawn 

from  Albarran). 

in  such  cases  cannot  be  entirely  relied  upon  on  account  of  the 
difficulties  which  arise  from  the  irritation  caused  by  the  reten- 
tion urethral  catheter.  Unfortunately,  it  is  so  difficult  to  properly 
drain  the  bladder  through  the  suprapubic  wound  that  any  other 
feasible  method  is  to  be  desired. 

The  method  of  primary  complete  repair  of  the  bladder  wall 
following  suprapubic  cystotomy  advocated  by  Albarran  is  prob- 


382 


DIAGNOSIS   AND   TREATMENT   OF    BLADDER   DISEASES 


ably  the  best,  and  is  as  follows:  The  retention  catheter  having 
been  placed  in  the  bladder  emerging  through  the  urethra,  the 
wound  in  the  bladder  is  sutured  with  catgut  ligatures  which  ap- 
proach to,  but  do  not  extend  through,  the  mucous  lining  of  the 
bladder.  A  small  amount  of  fluid  is  then  injected  into  the  blad- 
der through  the  urethral  catheter  and  the  wound  is  observed  to 


Fig.  144. — Suprapubic  cystotomy,  showing  the  two  sutures  of  catgut  which  attach 
the  bladder  to  the  muscle  and  the  two  wire  sutures  which  traverse  the  abdominal  wall 
(redrawn  from  Aibarran). 

see  whether  it  has  been  made  water-tight  or  not.  In  case  of 
leakage,  one  or  more  supplementary  sutures  are  then  made,  some- 
times a  U-suture  will  be  found  most  efficacious,  and  another  ob- 
servation is  made  as  to  whether  the  wound  is  water-tight  or  not. 
The  bladder  wound  having  been  closed  so  securely  that  there  is  no 
leakage  of  fluid,  a  second  layer  of  Lembert  sutures  is  placed  through 
the  bladder  wall,  which  fold  in  the  primary  layer  and  take  in 


SUPRAPUBIC    CYSTOTOMY 


383 


some  of  the  prevesical  fat  as  well.  These  having  been  put  in 
place,  one  suture  on  each  side  of  the  incision  into  the  bladder 
is  run  through  the  bladder  wall,  but  does  not  penetrate  the 
interior  of  the  bladder;  this  is  attached  to  the  under  surface  of 
the  muscles  surrounding  the  bladder,  but  does  not  penetrate  the 
skin.  This  holds  the  bladder  up  a  httle  closer  to  the  abdominal 
wall,  eliminating  to  some  extent  the  amount  of  dead  space.  Two 
silver  wire  sutures  are  then  run  through  the  skin  and  the  muscles 
and  fastened,  but  are  not  allowed  to  touch  the  bladder  wall  itself. 
This  is  somewhat  analogous  to  the  method  of  suturing  with  the 


145. — Guyon's  tube.  Fig.   146. — Freyer's  tube. 

silver  wire  recommended  by  Rousmorsky  Kopulloff,  mentioned 
in  a  previous  edition  of  this  book.  A  prevesical  drain  is  placed 
just  in  front  of  the  bladder  between  the  bladder  and  the  pubes, 
this  is  ordinarily  removed  forty-eight  hours  after  the  opera- 
tion. This  drain,  whether  a  tube  or  gauze,  does  not  penetrate 
the  bladder  wound.  The  silver  wire  is  removed  eight  days  after 
the  operation.  In  addition  to  the  silver  wire,  supplementary 
hgatures  through  the  skin  of  catgut  are  placed  in  position.  If 
possible  the  retention  catheter  is  kept  in  position  for  six  or  seven 
days,  when  a  new  one  is  put  in  its  place,  which  is  definitely  removed 
about  the  fourteenth"  day  following  the  operation,  and  the  patient 


384  DIAGNOSIS    AND    TREATMENT    OF    BLADDER    DISEASES 

is  allowed  to  sit  up  on  the  fifteenth  or  sixteenth  day.  We  recom- 
mend the  extra  size  silkworm  gut  in  the  place  of  the  wire  when 
impracticable  to  use  the  latter. 

If  there  is  an  infected  bladder  it  is  hopeless  to  attempt  to  get 
primary  union,  and  after  the  suprapubic  cystotomy  a  drainage- 
tube  should  be  placed  in  the  bladder,  but  the  general  plan  of  liga- 
tures should  be  as  that  outlined  above,  and  they  should  be  brought 
closely  up  to  the  tube,  so  as  to  leave  as  little  space  between  the 
tube  and  bladder  wall  as  possible. 

Concerning  the  size  of  the  tube  or  its  shape,  a  good  deal  will 
depend  on  the  individual  opinion  of  the  operator,  and  to  some 
extent  on  the  character  of  the  operation.  For  an  ordinary  opera- 
tion, such  as  stone  in  the  bladder  or  for  the  relief  of  a  small  rtumo, 
of  the  bladder,  a  small  rubber  tube  will  suffice.  Following  an 
operation  such  as  prostatectomy  or  for  the  relief  of  a  larger  tumor 
a  large  tube,  such  as  the  Frayer  tube,  may  prove  the  most  service- 
able. A  double-current  tube  may  be  used,  like  the  Guyon,  an 
illustration  of  which  is  given  in  the  text. 

When  a  tube  is  allowed  to  remain  in  the  bladder  for  the  purpose 
of  effecting  drainage,  the  bladder  may  be  irrigated  with  a  solution 
of  boric  acid  through  the  tube,  or  through  the  retention  catheter 
if  one  is  used,  several  times  a  day.  The  older  operative  methods 
of  opening  the  bladder,  such  as  by  lateral  lithotomy,  have  become 
almost  obsolete,  and  their  description  is,  therefore,  unnecessary. 
The  removal  of  stones  from  the  bladder,  when  any  cutting  opera- 
tion is  performed,  is  generally  accompHshed  through  a  suprapubic 
incision. 

Lateral  Incision. — It  is  the  custom  of  some  surgeons,  in- 
stead of  making  a  longitudinal  incision  in  the  bladder  in  the 
performance  of  a  suprapubic  cystotomy,  to  make  a  lateral  cut, 
keeping  as  close  to  the  pubic  symphysis  as  possible,  and  at  right 
angles  to  it,  the  contention  being  that  thus  more  room  is  obtained 
and  the  danger  of  wounding  the  peritoneum  is  diminished.  The 
writers  have  seen  one  or  two  cases  operated  on  in  this  manner, 
and  although  the  method  seems  practicable,  it  does  not  appear  to 
offer  any  great  advantages.  Some  surgeons  advocate  that,  during 
the  performance  of  a  suprapubic  c^^stotomy,  when  the  prevesical 
fat  is  encountered,  the  operator  should  introduce  a  finger  just 


CYSTOSTOMY  385 

under  the  edge  of  the  pubes  and  press  upward.  In  this  manner 
the  fat  may  be  pushed  up  out  of  the  way,  and  will  carry  with 
it  the  fold  of  peritoneum,  which  has  a  tendency  to  drop  down 
over  the  front  of  the  bladder.  By  this  means  also,  it  is  claimed, 
the  bladder-walls  may  be  distinctly  made  out,  both  by  their 
appearance  and  by  the  presence  of  the  veins  adhering  to  their 
outside  surface.  Theoretically,  this  may  be  true,  but  prac- 
tically, under  ordinary  circumstances,  and  if  the  operation  is 
one  in  which  haste  is  required,  too  much  time  cannot  be  wasted 
on  very  fine  dissections,  but  it  is  well  to  find  the  juncture  of  the 
peritoneum  with  the  bladder. 

An  interesting  case  of  suprapubic  fistula  came  under  the  writers' 
observation  some  years  ago.  The  patient  suffered  from  paralysis 
of  the  compressor  urethrse  muscles  following  a  perineal  incision, 
and  also  from  an  operative  suprapubic  fistula.  When  he  stood 
erect,  the  urine  ran  out  through  the  urethra;  but  when  he  lay  flat 
on  his  back,  it  escaped  through  the  suprapubic  opening.  Since 
seeing  this  case  the  writers  recommend  that,  in  bladder  operations, 
the  head  of  the  bed  be  sUghtly  elevated  to  permit  of  thorough 
drainage  downward.  In  making  permanent  suprapubic  fistulas 
sutures  not  easily  absorbable  should  be  used  to  attach  the  blad- 
der to  the  abdominal  wall,  or  a  long  retention  catheter  may  be 
emplo5''ed  when  such  attachment  is  undesirable, 

CYSTOSTOMY 

Cystostomy. — Cystostomy  is  the  term  applied  to  the  operation 
of  making  a  permanent  suprapubic  fistula.  It  is  particularly 
useful  as  a  palliative  operation  for  inoperable  tumors.  The  open- 
ing should  be  made  in  the  bladder-wall  well  down  to  the  pubes. 
Various  modifications  of  this  simple  operation  have  been  suggested, 
some  of  them  with  the  idea  that  the  permanent  suprapubic  opening 
can  be  made  to  act  like  a  sphincter  over  which  the  patients  will 
have  control  to  a  considerable  extent. 

A  practical  way  is  to  sew  the  bladder-wall  around  a  cath- 
eter and  drop  the  bladder  to  its  original  position,  and  until  the 
heahng  occurs  to  pack  gauze  between  catheter  and  symphysis. 
If  a  catheter  is  not  used,  it  is  necessary  to  fasten  the  mucous 
lining  of  the  bladder  to  the  skin.  If  the  catheter  is  not  used, 
25 


386  DIAGNOSIS   AND   TREATMENT   OF    BLADDER    DISEASES 


the  dressings  should  be  changed  frequently  and  the  stitching 
of  the  mucous  layer  to  the  skin  should  be  prepared  very  care- 
fully to  prevent  infiltration  into  the  space  of  Retzius.  After 
good  union  has  taken  place  between  the  mucous  membrane 
and  the  skin,  a  certain  proportion  of  patients  will  have  some 
voluntary  control  o\»er  the  fistula,  and  may  be  able  to  refrain 
from  soiling  the  dressing  for  several  hours  at  a  time.  Our  per- 
sonal experience  with  the  retention  catheter  through  the  supra- 
pubic opening  has  been  good  where  the  patient  has  been  confined 
to  a  recumbent  position,  but  if  the  patients  are  to  be  allowed  to 
walk  about,  the  permanent  fistula  without  the  catheter  is  the  most 


Fig.  147- — Operation  of  cystostomy. 
Sewing  of  muscular  layer  of  bladder  to 
abdominal  muscles  (redrawn  from  Pierre 
Duval). 


Fig.  148. — Operation  of  cystostomy. 
Sewing  of  mucous  layer  to  skin  (redrawn 
from  Pierre  Duval). 


desirable.  In  our  experience  young  patients  with  good  muscular 
tissue  have  the  best  control  over  the  suprapubic  sphincter.  The 
two  illustrations  show  a  very  good  way  of  making  the  fistula. 
The  operation  can  be  divided  into  two  sections,  as  shown  in 
the  illustration.  The  first  part  consists  in  the  fixation  of  the 
muscular  portion  of  the  bladder-wall  to  the  abdominal  muscle. 
On  each  side  a  stitch  is  run  through  the  muscular  wall  of  the 


CYSTOSTOMY  387 

bladder  and  through  the  inner  surface  of  the  abdominal  muscle, 
not  penetrating  the  skin.  Then  a  stitch  is  run  one  above  and  one 
below  these  side  stitches,  which  penetrates  the  muscular  layer  of 
the  bladder,  and  each  cf  the  two  abdominal  muscles  some  inches 
from  their  border.  Above  and  below  the  abdominal  wall  is 
sutured  to  the  skin.  All  this  is  shown  in  the  first  illustration. 
Then  the  bladder  is  opened  in  the  median  line  and  the  second  part 
of  the  operation  is  proceeded  with,  which  is  shown  in  the  second 
illustration.  This  consists  in  the  suture  of  the  mucous  lining 
of  the  bladder  to  the  skin.  Two  lateral  sutures  take  in  the  skin 
and  the  mucous  lining  of  the  bladder.  Then  a  stitch  above  and 
a  stitch  below  penetrate  the  skin  on  two  sides  and  in  two  places 
the  vesical  mucous  membrane.  The  vesical  orifice  ought  to  be 
situated  as  near  as  possible  to  the  bladder. 

Suprapubic  fistulas  resulting  from  operations  frequently  become 
a  source  of  much  annoyance.  They  are  more  often  encountered 
in  hospital  than  in  private  practice,  and  usually  heal  with  diffi- 
culty. In  treating  a  case  of  suprapubic  fistula  following  a  pre- 
vious operation  it  is  well,  when  possible,  not  only  to  enlarge 
the  opening  and  freshen  the  edges  of  the  wound,  as  advised  in 
most  works  on  surgery,  but  also  carefully  to  examine  the  bladder 
for  the  purpose  of  detecting  any  foreign  substance  that  may  have 
been  left  behind  after  the  operation  or  which  may  have  subse- 
quently formed.  The  writers  have  seen  one  case  in  which  non- 
absorbable ligatures  were  found  in  the  bladder  and  were  the  appar- 
ent cause  of  the  fistula ;  in  another  case  a  piece  of  gauze  was  found 
that  was  responsible  for  the  non-union  of  the  bladder  wound. 

In  the  case  of  a  medical  friend,  who  had  been  operated  upon  for 
papilloma  of  the  bladder,  the  cause  for  the  suprapubic  fistula 
was  found  to  be  a  piece  of  gauze,  one  yard  long  and  two  inches 
wide,  that,  through  carelessness,  was  left  behind  after  the  opera- 
tion. The  urethra  and  meatus  being  large,  the  gauze  eventually 
showed  itself  through  the  urethra  to  such  an  extent  as  to  make  its 
presence  known  to  the  attending  physician,  who  extracted  it 
through  the  urethral  canal. 

If  the  interior  of  the  bladder  has  been  examined  and  nothing 
has  been  found  to  account  for  the  presence  of  the  fistula,  the  edges 
of  the  wound  may  be  freshened  and  sutured  with  a  deep  and  a 


388  DIAGNOSIS    AND   TREATMENT   OF    BLADDER   DISEASES 

superficial  layer  of  sutures,  a  retention  catheter  being  introduced 
through  the  urethra  or  a  perineal  opening  for  drainage  made. 
It  has  been  our  experience  that  some  of  these  cases  have  a 
tendency  to  fistula  formation.  It  is  wise  to  try  the  effect  of  a 
retention  catheter  before  doing  perineal  section,  for  sometimes 
in  the  latter  event  the  suprapubic  fistula  will  heal  but  a  perineal 
fistula  will  develop.  Some  suprapubic  fistulas  do  well  with  occa- 
sional applications  of  nitric  acid  or  the  cautery.  Often  in  such 
cases,  particularly  if  there  is  any  tubercular  tendency,  change  of 
air  or  residence  in  the  country  will  have  a  curative  effect.  Other 
methods  failing,  plastic  operations  must  be  resorted  to. 

TREATMENT  OF  BLADDER  TUMORS 
The  symptoms  of  bladder  tumor  are  painful  micturition,  changes 
in  the  urine,  generally  the  presence  of  blood  in  the  urine,  and  not 
infrequently  pain  in  the  neighborhood  of  the  bladder.  Tumor 
of  the  bladder  may,  however,  exist  for  years  without  causing  any 
symptoms  at  all.  Such  tumors  are  non-malignant  and  generally 
small  in  size.  One  quite  common  characteristic  of  most  bladder 
tumors,  and  even  of  cancer,  is  the  fact  that  they  are  very  slow  in 
their  progress,  even  after  the  symptoms  have  shown  themselves. 
Fatal  results  most  frequently  occur  not  from  them,  but  from  the 
invasion  of  other  organs. 

The  diagnosis  is  generally  comparatively  easy  on  account  of 
the  history  of  the  case,  and  can  ordinarily  be  settled  positively 
by  a  cystoscopic  examination  performed  by  one  familiar  with  such 
work.  It  sometimes  happens,  in  our  own  experience,  as  in  that 
of  other  observers,  that  the  contraction  of  the  bladder  and  the 
easy  bleeding  of  the  bladder  surface  connected  with  a  cancer  or 
other  tumor  of  the  bladder  renders  it  very  difficult  to  make  a 
satisfactory  cystoscopic  examination,  viz.,  on  account  of  the 
inability  of  the  bladder  to  hold  sufficient  fluid  and  the  impos- 
sibility of  having  the  fluid  in  the  bladder  clear  enough  to 
obtain  a  proper  view.  In  such  cases  a  careful  examination 
by  means  of  a  Thompson  searcher  may  make  the  diagnosis 
very  clear.  The  use  of  this  instrument  has  been  described  in  a 
previous  portion  of  the  book.  The  tumor  should  be  investigated 
by  a  similar  method  to  that  employed  in  searching  for  stone,  and 


TREATMENT  OF  BLADDER  TUMORS 


389 


in  measuring  for  the  purpose  of  obtaining  an  accurate  idea  of  the 
size  of  the  prostate.  Particularly  in  searching  for  tumor  is  it 
important  to  turn  the  instrument  so  that  the  beak  will  point 
toward  each  side  of  the  bladder,  then  withdraw  it  as  far  as  possible, 
and  measure  the  distance.  Diagnosis  by  this  method  can  be  made 
in  certain  cases,  as  has  recently  been  demonstrated  by  one  of  us. 

The  tumor  of  the  bladder  having  been  located,  various  proced- 
ures may  be  instituted  for  its  removal. 

The  suprapubic  route  is  the  most  popular.  After  the  bladder 
has  been  opened  in  the  classical  manner,  a  careful  inspection  of 
the  tumor  and  of  the  urethral  and  the  ureteral  orifices  should 
be  made.     If  it  is  desired,  one  of  the  bladder  specula  so  frequently 


Fig.  149- 


Fig.  150. 


Fig.  149- — Showing  method  of  making  cone  and  h'ne  of  incision.  Cone  is  com- 
posed of  the  mucous  layer  and  superficial  muscular  layer.  The  mucous  layer  is  incised 
in  a  circular  manner  and  the  muscular  layer  resected  as  a  cone  from  its  submucous  couch. 

Fig.  150. — Scheme  showing  how,  in  extirpation  of  a  tumor  as  in  preceding  illus- 
tration, there  is  a  superficial  removal  of  the  muscular  layer  underneath  the  tumor,  cone 
shaped  (redrawn  from  Pierre  Duval). 


used  by  the  French  surgeons  may  be  employed  to  distend  the 
wound  and  hold  it  open.  It  is  our  custom  to  use,  in  operating 
on  the  bladder,  the  very  small  electric  light  attached  to  a  flexible 
cord,  called  by  electricians  a  pea-light,  which  is  let  down  into  the 


390 


DIAGNOSIS    AND   TREATMENT    OF    BLADDER    DISEASES 


bladder  and  which  well  illuminates  its  surface.  It  will  probably 
not  be  necessary  in  the  small  pediculated  growths  of  the  bladder 
to  do  more  than  to  nip  off  the  growth  from  the  pedicle  and  cau- 
terize the  base  lightly.     Except  in  cases  of  very  small  growths 


Fig.    151. — Method  of   closing  cavity  in  bladder  from  which  tumor  has  been   removed 
(redrawn  from  Pierre  Duval). 

they  should  be  removed  by  an  incision  into  the  mucous  membrane 
of  the  bladder,  the  growth  removed,  and,  whenever  possible,  the 
wound  in  the  mucous  membrane  left  by  the  removal  of  the  tumor 
brought  together  by  sutures.  This  manner  of  removing  tumors 
of  the  bladder  is  shown  in  figs.  149,  150,  151),  Great  care  should 
be  used  to  gain  as  much  union  as  is  possible  of  the  mucous  mem- 
brane wound.  Growths  of  larger  extent,  if  deep,  may  require 
a  deep  incision,  sometimes  into  the  perivesicular  tissues  for  their 


Fig.  IS2.— Showing  how,  in  some  implanted  bladder  tumors,  a  pedicle  can  be  made 
by  exerting  traction  on  two  transfixion  needles  introduced  at  right  angles  to  each  other. 
a,  b,  Transfixion  needles  (redrawn  from  Pierre  Duval). 

removal.  If  the  neoplasm  involves  the  orifice  of  the  ureter,  the 
ureteral  orifice  should  be  made  in  another  portion  of  the  bladder. 
The  manner  of  removing  a  growth  attached  to  the  extremity  of 
the  ureter  is  illustrated  in  Figs.  156  and  157). 


TREATMENT  OF  BLADDER  TUMORS 


391 


In  order  to  prevent  hemorrliage  in  removing  a  growth  from  the 
bladder  it  is  wise  to  place  the  catgut  hgatures  in  position,  when 


Fig.    1 53-— Illustrating  the  placing  of  the  forceps  at  base  of  cone  formed  by  the  trans- 
fixion needles  (redrawn  from  Pierre  Duval). 


Fig.    154.— Resection  of  the  bladder  wall  (redrawn  from  Albarran). 


possible,  which  are  to  be  used  in  sewing  up  the  mucous  membrane 
at  the  base  of  the  growth,  before  removing  the  growth.     This 


392 


DIAGNOSIS   AND   TREATMENT    OF    BLADDER    DISEASES 


makes  it  a  little  easier  to  control  any  hemorrhage  which  may  ensue 
after  the  removal  of  the  growth.  Albarran  suggests  that  if  after 
hemorrhage  still  continues,  a  few  stitches  should  be  put  in  position 
running  diagonally  across  the  field,  which  will  tend  to  make  pres- 
sure from  a  different  direction. 

If  an  infiltrating   growth  be  present,  which  is  also  extensive, 
and  such  growths  are  generally  malignant,  a  more  difficult  situ- 


Fig.   iss.— Resection  of  the  bladder.     Suture  of  the  wall  (redrawn  from  Albarran). 

ation  is  presented.  It  is,  of  course,  well  recognized  that  some  of 
the  bladder  tumors  which  are  not  malignant  are  associated  with 
similar  timiors  in  adjacent  organs.  Papilloma  of  the  bladder 
and  papilloma  of  the  kidney  are  liable  to  exist  together,  while 
malignant  growths  of  the  bladder  are  very  apt  to  be  associated 
with  the  involvement  of  other  organs,  like  the  prostate.     It  has 


TREATMENT   OF    BLADDER   TUMORS 


393 


seemed  to  us,  from  our  clinical  experience,  where  a  growth  in  the 
bladder  is  malignant  from  a  transformation  of  a  previous  benign 
bladder  tumor,  it  is  less  liable  to  be  associated  with  malignant 
growth  elsewhere. 

Malignant  tumors  of  the  bladder  should  be  treated  on  the  same 
lines  as  those  laid  down  for  benigh  tumor,  except  that,  when  practi- 
cal, it  is  wise  to  remove  the  prostate  at  the  same  operation,  and  some 
have  advocated  the  removal  of  the  adjacent  lymph-nodes.  Lymph- 
node  hypertrophy  may  be  largely  inflammatory,  and  true  metasta- 
sis of  the  cancer  not  have  taken 
place.  If  the  cancer  is  extensive, 
and  has  not  involved  the  base  of 
the  bladder,  a  palliative  opera- 
tion, such  as  cystostomy,  should 
ordinarily  be  the  method  of 
choice,  or  the  bladder  may  be 
ablated,  the  meters  transposed 
to  the  intestine  or  the  skin,  or 
nephrotomy  may  be  performed. 
If  there  is  considerable  involve- 
ment of  the  surrounding  tissues, 
and  the  patient  is  not  suffering 
much  pain,  in  oiu"  experience 
cystostomy  renders  them  quite 
comfortable,  and  the  disease  may  go  on  for  some  time  without 
causing  marked  changes  in  their  physical  well-being.  If  the  can- 
cer is  more  toward  the  fundus  of  the  bladder,  partial  resection  of 
the  bladder  may  be  attempted,  with  or  without  the  transplanta- 
tion of  the  ureters. 

In  performing  resection  the  shape  of  the  part  which  is  to  be 
removed  should,  if  possible,  be  of  such  a  character  that  a  good 
apposition  of  the  surfaces  left  after  the  removal  of  a  portion  of 
the  bladder  can  be  made.  The  most  useful  form  for  the  incision 
to  take  is  well  illustrated  in  the  two  pictures  presented.  The 
sutures  should  be  so  placed  following  a  partial  removal  of  the 
bladder  of  this  character,  that  if  possible  they  should  not  pene- 
trate the  mucous  surface  of  the  bladder. 

Partial  resection  of  the  bladder  is  sometimes  quite  successful; 


Fig.  156. — Illustrating  line  of  incision  for  re- 
moval of  bladder  tumor  involving  orifice  of  ure- 
ter (redrawn  from  Pierre  Duval). 


394         DIAGNOSIS   AND   TREATMENT   OF   BLADDER   DISEASES 


it  is  necessary,  however,  to  leave  about  one-half  of  the  bladder 
to  carry  on  its  functions. 

The  question  of  drainage  after  the  removal  of  a  growth  in  the 
bladder  is  quite  an  important  one.  Where  very  small  non-malig- 
nant growths  exist  which  have  been  simply  tied  off  without  incis- 
ing the  mucous  mem- 
brane to  any  extent, 
the  bladder  wound 
should  be  sewn  up 
immediately  and  the 
bladder  allowed  to 
drain  through  a  reten- 
tion catheter  through 
the  urethra.  In  cases 
where  the  bladder  has 
not  been  infected  and 
the  growth  has  been  of 
moderate  size  and  it 
has  been  possible  to 
bring  the  mucous 
membrane  opening 
from  which  the  growth 
was  removed  into  good 
apposition,  the  same  procedure  may  be  tried.  Where  the  growth  has 
been  large,  and  where  it  has  been  impossible  to  close  accurately  the 
mucous  membrane  incision,  suprapubic  drainage  should  be  instituted 
through  a  Freyer's  tube.  No  tube  should  be  allowed  to  penetrate  to 
the  bottom  of  the  bladder,  and  irrigation  should  be  made  most  gently 
for  the  first  four  or  five  days,  so  as  not  to  disturb  any  clot  which  may 
form  at  the  place  from  which  the  growth  has  been  removed. 

The  Nitze  operating  cystoscope,  previously  described,  is  an 
ingenious  apparatus  through  the  aid  of  which  a  galvanic  cautery 
snare  can  in  some  cases  be  placed  about  the  pedicle  of  the  tumor, 
and  so  be  snared  and  cauterized  off  without  necessitating  opening 
of  the  bladder.  The  various  attachments  are  so  arranged  that 
the  snare  can  be  thrown  out  at  different  angles.  Up  to  the  present 
time  comparatively  little  work  has  been  done  with  these  instru- 
ments by  American  surgeons,  although  one  or  more  of  them  have 
designed  operating  cystoscopes.     This  method  will  undoubtedly 


Fig.  157. — Illustrating  further  removal  of  tumor  with  end  of 
ureter.  Showing  insertion  of  ligatures  and  ligation  of  accom- 
panying venous  pedicle  (redrawn  from  Pierre  Duval) . 


TREATMENT  OF   BIvADDER   TUMORS 


395 


come  into  more  general  favor  as  we  become  more  familiar  with 
the  use  of  the  cystoscope,  mainly  for  the  following  reason:  It 
is  well  known  by  all  who  have  had  occasion  to  operate  on 
bladder  tumors  through  the  suprapubic  route  that  they  tend  to 
recur,  and  it  can  easily  be  seen  that  any  .  . , 

measure  that  will  obviate  the  necessity  for 
frequently  reopening  the  bladder-wall  will 
be  regarded  with  satisfaction  by  both  pa- 
tient and  surgeon. 

The  method  of  treatment  of  recurring 
bladder  growths  through  the  high-frequency 
current  has  already  been  mentioned  earlier 
in  the  volume.  The  spark  given  off  through 
the  high-frequency  current  has  a  cauteriz- 
ing effect,  or  some  other  form  of  cauter- 
ization of  these  growths  may  be  attempted 
when  desired  through  the  instrumentality 
of  the  operating  cystoscope.  Other  cysto- 
scopic  treatment  of  these  bladder  growths 
may  be  instituted  through  the  Schapira 
cystoscope  previously  mentioned,  or  what- 
ever form  of  opiating  cystoscope  with 
which  the  surgeon  is  most  familiar. 

SyphiUtic  ulcers  and  neoplasms  of  the  bladder,  which  have  been 
previously  mentioned  under  the  Pathology  of  Bladder  Diseases,  we 
believe  and  have  stated  in  previous  editions  of  this  work  to  be  very 
frequently  the  cause  of  chronic  cystitis  with  contracted  bladder. 
Before  the  more  common  use  of  the  cystoscope  clinical  experience 
seemed  to  show  that  contracted  bladder  and  syphilis  went  hand  in 
hand.  It  is  apparent  now  that  these  contractions  are  probably  due 
to  the  after-formation  of  cicatricial  tissue  following  syphilitic  ulcera- 
tion. The  intermittent  hematuria  is  an  occasional  symptom,  and 
under  the  cystoscope  ulcers  deep  or  superficial,  single  or  multiple 
may  be  found  in  their  late  stages,  that  of  gumma  sometimes  resem- 
bling true  bladder  tumors.  According  to  G.  Gayet  et  Favre  (Journal 
d'Urologie,  July,  19 14)  these  are  not  infrequently  seen  in  old  syph- 
ilitics  who  may  have  locomotor  ataxia  or  myelitis  or  other  syphilitic 
affections  of  the  nervous  system.  Where  there  is  any  evidence  point- 
ing toward  syphilis,  the  proper  constitutional  treatment  should  be 


Fig.  158. — Suture  of  the 
resected  ureter  in  the  supe- 
rior border  of  the  bladder 
wound;  suture  of  the  blad- 
der (redrawn  from  Pierre 
Duval). 


396 


DIAGNOSIS  AND   TREATMENT   OF  BLADDER   DISEASES 


instituted,  extending  for  quite  a  long  period  of  time,  several  weeks, 
and  its  effects  observed  on  the  bladder  by  inspection,  in  a  case  of 
doubtful  tumor,  before  resorting  to  operation.  It  has  been  our 
experience  that  often  syphilitic  affections  of  the  urinary  tract  are 

slow  to  yield  to  treat- 
ment and  that  active 
treatment  should  be  per- 
sisted in  for  several  weeks 
before  the  local  mani- 
festations are  necessa- 
rily much  ameliorated. 
Gayet  et  Favre  were  in 
accord  with  this  view, 
and  mentioned  one  case 
in  which  ten  weeks  were 
required  before  a  syphi- 
litic ulcer  of  the  bladder 
was  healed. 

Foreign  Bodies  in  the 
Bladder. — These  may  or 
may  not  present  symp- 
toms. Cystoscopic  ex- 
amination, however,  will 
generally  reveal  their 
presence,  if  the  searcher 
has  not  already  done  so. 
In  doubtful  cases  an 
x-TSLj  picture  may  be 
taken.  When  found,  they 
can  often  be  removed 
with  the  lithotrite,  with 
long  forceps,  the  forceps 
being  in  a  tube  contain- 
ing a  cystoscope, — an 
instrument  devised  by 
Casper, — or  by  making  an  opening  into  the  bladder.  It  is  the 
writers'  experience  that  when  fistula  follows  bladder  operations 
or  the  removal  of  stone,  the  condition  is  often  due  to  material 
left  behind,  such    as    dressings    or   unabsorbed   ligatures;    they 


Fig.  159. — Apparatus  used  after  Sonnenberg's  operation  for 
exstrophy  of  the  bladder. 


EXSTROPHY   OF   THE   BLADDER 


397 


therefore  recommend  that  a  thorough  search  be  made  for  foreign 
bodies  at  the  time  any  procedure  for  the  closing  of  fistula  is 
inaugurated. 

EXSTROPHY  OF  THE  BLADDER 

This  dreadful  condition  is  a  congenital  one,  and,  fortunately, 
of  very  rare  occurrence.  It  is  due  to  non-closure  of  the  abdominal 
cleft.     It  may  be  partial,  so  that  only  a  slight  fissure  is  left  near 


%, 


^  ^fft-.  .'-/ 


Fig.  i6o. — Scar  on  abdomen  after  Sonnenberg's  operation  for  exstrophy  of  the  bladder. 

the  urachus  or  at  the  lower  angle  of  the  cleft.  If  sUght,  stimula- 
tion of  the  edges  or  a  sHght  plastic  operation  may  result  in  closure. 
When  complete  in  children  so  afflicted  the  anterior  bladder-waU 
is  absent,  so  that  the  posterior  bladder-wall  presents  itself  in  the 
front  of  the  abdomen.  In  males,  epispadias  coexists;  hence 
such  subjects,  if  they  live  to  attain  adult  life,  are  so  mahormed 
that  their  genital  organs  are  useless. 

A  great  variety  of  operations  have  been  performed  for  the  at- 


398 


DIAGNOSIS   AND   TREATMENT   OF    BLADDER   DISEASES 


tempted  cure  or  relief  of  this  distressing  condition.  So  far  as  cure 
is  concerned,  these  operations  have  all  proved  unsuccessful.  The 
results  so  far  as  relief  is  concerned  are,  however,  somewhat  better. 
Only  an  outline  of  the  operations  for  the  relief  of  this  condition 
will  be  given  here.  In  a  general  way  the  operations  that  have 
been  attempted  may  be  divided  into  three  classes : 


Fig.  i6i. — Maydl's  method  for  exstrophy  of  the  bladder.  The  abdomen  is  opened  by  an 
incision  around  the  upper  part  of  the  bladder,  using  one  or  two  fingers  introduced  into  the 
abdominal  cavity  as  a  guide  ;  the  sides  of  the  bladder  are  then  separated.  The  peri-ureteral 
portion  to  be  incised  is  shown  by  the  dotted  line. 

Class  i. — This  consists  in  separating  the  symphysis  pubis  in 
an  attempt  to  fold  and  unite  the  two  sides  of  the  bladder-wall  so  as 
to  make  a  complete  bladder,  an  operation  being  performed  at 
the  same  time  for  the  relief  of  the  hypospadias — in  other  words, 
to  unite  the  borders  of  the  bladder.  There  are  several  different 
modifications  of  this  method. 


EXSTROPHY   OF   THE    BLADDER 


399 


Class  2. — This  consists  of  various  methods  of  grafting  skin 
from  a  neighboring  part  or  from  the  intestinal  region,  transplant- 
ing also  a  portion  of  mucous  membrane,  with  the  idea  of  making 
a  cavity  that  will  act  as  a  bladder. 

Class  3. — Measures  that  consist  in  excising  the  bladder  entirely 
and  transplanting  the  ureters  into  the  intestinal  canal — generally 


Fig.  162. — Maydl's  method  of  operation  for  exstrophy  of  the-bladder.  The  sigmoid 
flexure  is  incised  along  its  free  border,  and  is  then  fastened  to  the  peri-ureteral  portion  of  the 
bladder  with  catgut  sutures. 

into  the  rectum.  The  writers  have  never  had  the  opporttmity  of 
operating  on  a  case  of  this  kind,  but  one  has  been  brought  under 
their  observation  that  was  operated  on  according  to  the  last-des- 
cribed method  by  Dr.  Frank  Hartley,  of  New  York.  The  patient 
was  aHve  several  years  subsequent  to  the  operation,  and  the 
rectum  seemed  very  tolerant  to  the  urinary  flow.    This  is  the  opera- 


400 


DIAGNOSIS   AND   TREATMENT   OF    BLADDER   DISEASES 


tion  of  Maydl.  The  illustrations  (figs.  i6i,  162,  163)  furnish  a  clear 
idea  of  its  nature.  In  this  class  also  may  be  considered  a  series  of 
operations  that  consist  in  transplanting  the  ureters  into  the  penal 
gutter — the  method  of  Sonnenberg,  of  which  two  illustrations  are 
given  (figs.  159,  160).  The  bladder  is  entirely  removed  in  this 
method   and   it   necessitates  the    constant   wearing  of   a  urinal. 


■  w  ■■■■'■  ■'■■■■' 


Fig.  163. — Maydl's  method  of  operation  for  exstrophy  of  the  bladder.  The  peri-Hreteral 
portion  of  the  bladder  is  inserted  into  the  opening  in  the  sigmoid  and  the  edges  sutured 
together. 


(These  operations  are  described  in  considerable  detail  by  Berger 
and  Hartmann  in  their  "Text-book  of  Surgery,"  vol.  ix;  they  also 
commend  the  article  of  Katz,  "Traitemente  Chirurgical  de  I'Ex- 
trophie  de  Vessie,"  "These  de  Paris,"  1902-03,  No.  535,  G.  Stein- 
heil,  editor.) 

Also  should  be  considered  in  this  class  the  method  of  Segond, 


EXSTROPHY  OF  THE  BLADDER 


401 


illustrated  in  figs.  164,  165,  166.  This  method  consists  in 
dissecting  out  the  wall  of  the  bladder  pretty  well  down  to  the 
attachment  of  the  ureters;  then  doubling  it  over  and  attaching 
it  to  the  penal  gutter;  then  making  a  hole  in  the  underlying 
prepuce  and  pushing  the  gutter  through  so  that  the  prepuce 
makes  a  hood.     The  bladder  flap  should  be  trimmed  to  fit,  as 


Fig.  164. — Segond's  operation  for  exstrophy  of  the  bladder.  Tho  under  surface  of  the  bladder- 
wall  is  pushed  up  and  dissected  along  the  dotted  lines;  it  is  then  brought  down  upon  the  penal 
gutter. 


the  dotted  fines  in  Fig.  164  show.     The  edges  of  the  penal  gutter 

should  be  freshened  to  unite  them  with  the  bladder  flap.     As 

much  vesical  tissue  as  possible  should  be  left  around  the  ureters 

when  the  flap  is  turned  over.     The  upper  border  of  the  preputial 

hood  can  be  united  to  and  will  help  cover  the  opening  in  the 
26 


402 


DIAGNOSIS   AND   TREATMENT   OF    BLADDER    DISEASES 


abdominal  wall  left  by  the  removal  of  the  bladder;   if  necessary, 
side  flaps  can  be  made  to  help  cover  in  this  latter. 

We  have  very  recently  received  from  Dr.  John  T.  Bottomley, 
of  Boston,  Mass.,  the  report  of  a  case  of  exstrophy  of  the  bladder 
treated  by  what  seems  to  us  a  very  practical  method,  and  that  is 


Fig.  165. — Segond's  operation  for  exstrophy  of  the  bladder.     The  borders  of  the  penal 

f utter  and  of  the  adjacent  skin  are  freshened,  the  dissected  portion  of  the  bladder-wall  is 
rought  down  upon  the  penal  gutter,  and  the  two  first  sutures  (i)  are  put  in  each  side.  The 
adherent  border  of  the  prepuce  is  then  punctured  transversely  and  turned  inside  out,  and  is 
spread  apart  by  the  retractor  to  show  the  e.xtent  of  the  raw  surface  which  is  to  be  brought  up 
over  the  portion  of  bladder- wall. 

the  removal  of  the  bladder  which  is  preceded  by  the  transplan- 
tation a  few  days  earlier  of  the  ureters  to  the  skin  of  the  loins. 
He  has  recently  operated  on  a  patient  by  this  method,  the  report 
of  the  operation,  as  kindly  furnished  us  by  him,  is  as  follows: 
"Through  an  incision  on  either  side  of  the  abdomen  about 


EIXSTROPHY   OF   THE    BLADDER 


403 


parallel  with  the  crest  of  the  ilium  go  to  the  peritoneum;  the 
latter  structure  is  pushed  forward,  the  ureter  on  either  side  is 
foimd,  freed,  cut  across  at  the  point  where  it  crosses  the  iUac 

vessels,  and  through  a  small  stab  wound  in  the  loin  the  end  is 


■mi''- 

•'•\"'  '■."('"'u'i'IKv-'  '  '-  -'■ 


^^. 


Fig.  166. — Segond's  operation  for  exstrophy  of  the  bladder.  The  dissected  portion  of  the 
bladder  has  been  folded  down  and  fastened  on  each  side  with  the  sutures  (i,  i),  and  the 
preputial  hood  has  been  raised  over  the  penis  and  the  raw  surface  of  the  dissected  portion  of 
the  bladder.  The  sutures  (2,  2)  fix  the  shape  of  the  meatus.  The  sutures  (1,1)  have  been 
passed  through  the  prepuce  so  as  to  be  removed  afterward.  The  prepuce  is  lifted  aside  to 
show  the  course  of  the  suture  (i)  on  the  right  side.  The  suture  (3)  reunites  the  skin  of  the 
penis,  the  freshened  border  of  the  penal  gutter,  the  dissected  portion  of  the  bladder,  and  the 
preputial  hood.  The  suture  (4)  closes  carefully  the  vesical  fold  near  the  ureter.  The  suture 
(5)  will  lift  up  the  prepuce  and  fasten  it  to  the  skin  of  the  abdomen. 


carried  out  on  to  the  skin  of  the  loin  and  held  there  b}^  sutures 
to  the  skin,  about  one-eighth  inch  of  the  ureter  being  allowed  to 
project.  Ten  days  after  the  preliminary  operation  the  ectopic 
bladder  is  removed;   the  denuded  area  is  covered  in  by  grafting 


404  DIAGNOSIS   AND   TREATMENT   OP    BLADDER   DISEASES 

and  by  skin  flaps.  The  patient  wears  an  apparatus  for  collecting 
the  urine,  is  really  very  comfortable,  there  is  no  urinous  odor, 
and  the  apparatus  keeps  the  patient  dry."  Mr.  Reginald  Harri- 
son,* in  1896,  treated  a  case  by  removing  one  kidney  and  then 
transplanting  the  ureter  of  the  remaining  kidney  to  the  skin  of 
the  corresponding  loin.  Dr.  Bottomley  in  performing  his  opera- 
tion attached  the  ureter  of  each  kidney  to  the  loin  on  the  corre- 
sponding side. 

INJURIES  OF  THE  BLADDER 

Injuries  of  the  urinary  bladder  occur  in  the  form  of  wounds, 
contusions,  and  rupture  of  the  organ.  In  dealing  with  an  injury 
of  the  bladder  it  is  important  to  determine  whether  the  lesion  is 
an  extraperitoneal  or  an  intraperitoneal  one.  Now  that  such 
great  advances  are  being  made  in  general  surgery  and  explora- 
tory incisions  for  the  purpose  of  ascertaining  the  extent  of  an 
injury  have  become  so  common,  together  with  the  fact  that  skil- 
ful operators  are  becoming  so  numerous,  it  hardly  seems  neces- 
sary to  divide  injuries  and  rupture  of  the  bladder  into  many 
different  classes,  each  to  be  considered  under  a  separate  head. 
The  most  exhaustive  work  that  has  been  done  on  this  subject, 
according  to  the  writers'  knowledge,  is  recorded  by  Duplay 
and  Reclus,  "Traite  de  Chirurgie,"  vol.  vii. 

The  bladder  is  rarely  wounded  in  its  anterior  aspect,  unless  the 
organ  is  very  much  distended,  for  the  reason  that,  when  empty 
or  only  partially  full,  it  is  protected  in  front  by  the  pubic  bone. 
It  is  more  often  wounded  as  the  result  of  a  penetrating  injury 
through  the  perineum,  as  from  falling  on  a  sharp  substance; 
through  the  rectum  or  through  the  back,  following  the  infliction 
of  a  stab  wound,  and  occasionally  from  the  toss  of  a  bull.  It  is 
also  not  infrequently  wounded  during  the  performance  of  some 
abdominal  operation,  particularly  during  hysterectomy.  Quite  a 
large  portion  of  the  bladder-wall  may  be  torn  off  either  from  the 
inside  or  as  the  result  of  injury  outside  of  the  bladder,  the  organ 
continuing  to  functionate  and  repair  of  the  wound  following. 

Wounds  of  the  bladder  are  very  seldom  uncomplicated,  being  al- 
most always  associated  with  wounds  of  some  other  organ.     Exper- 
iments and  observations  on  both  experimental   animals  and  on 
^Harrison,  Reginald:    "Lancet,"  1897. 


RUPTURE  OF  THE  BLADDER  405 

man  tend  to  show  that  nature  very  quickly  attempts  the  repair  of 
an  injury  to  the  bladder. 

If  the  wound  is  situated  intraperitoneally,  adhesions  from  the 
peritoneum  form  very  rapidly  and  tend  to  close  it  in.  If  extra- 
peritoneally,  it  closes  almost  as  rapidly.  A  considerable  portion 
of  the  bladder  substance  may  be  removed  and  cicatrization  and 
repair  still  go  on.  The  folds  of  the  wounded  bladder  tend  to  shut 
down  on  themselves  and  keep  the  urine  from  escaping  through 
the  wound. 

Painful  micturition,  bloody  urine,  and  shock  are  more  or  less 
constant  symptoms  of  bladder  injuries.  Later,  if  the  wound  has 
been  an  intraperitoneal  one,  these  symptoms  may  be  followed  by 
peritonitis  or  by  symptoms  of  purulent  cystitis.  A  fistula  may 
subsequently  be  established.  If  the  bladder  is  wounded  during 
an  operation  and  the  wound  is  immediately  sutured,  ordinarily 
but  Httle  trouble  follows.  Infiltration  of  urine  into  the  surround- 
ing tissues  may,  however,  follow  infliction  of  the  wound,  and  can 
generally  be  diagnosed  by  the  swelHng  caused  by  such  infiltration 
if  the  wound  has  been  an  extraperitoneal  one. 

The  treatment  of  wounds  of  the  bladder  is  as  follows : 

The  hemorrhage  should  be  checked,  foreign  bodies  removed, 
and  proper  care  observed,  by  the  use  of  antiseptic  measures  and 
drainage,  to  prevent  the  after-formation  of  fistula.  This  can  be 
accompHshed  by  the  introduction  of  a  retention  catheter  or  by 
making  a  perineal  or  suprapubic  incision.  In  all  doubtful  cases 
of  penetrating  wounds  of  the  lower  portion  of  the  abdomen  an 
exploratory  laparotomy  is  indicated. 

RUPTURE  OF  THE  BLADDER 
Rupture  of  the  bladder  is  probably  somewhat  more  common 
than  are  wounds  of  the  bladder.  It  may  be  the  result  of  injury 
or  of  overdistention  of  a  diseased  bladder.  Rupture  has  been 
known  to  follow  overdistention  due  to  the  employment  of  too 
large  a  quantity  of  an  irrigating  fluid  by  the  surgeon.  It  would 
be  interesting  to  observe  how  many  cases  of  rupture  of  the  bladder 
occur  in  drunkards  either  from  overdistention  or  from  injury. 
Rupture  of  the  bladder  may  occur  either  extraperitoneally  or 
intraperitoneally,  the  latter  being  by  far  the  most  common.      The 


4.o6  DIAGNOSIS    AND   TREATMENT   OF    BLADDER   DISEASES 

site  of  the  rupture  is  generally  at  the  back  or  at  the  bottom  of  the 
bladder.  The  rupture  that  occurs  in  fractures  of  the  pelvis  is 
more  likely  to  be  extraperitoneal.  The  rent  is  generally  a  vertical 
or  an  oblique  one. 

The  symptoms  of  rupture  of  the  bladder,  like  those  of  wounds 
of  the  bladder,  consist  of  shock,  which  is  particularly  marked 
in  those  cases  in  which  the  rupture  is  due  to  some  abdominal 
injury.  In  other  cases  the  shock  is  not  so  marked.  Tenesmus 
and  hemorrhage  are  generally  associated.  If  sought  for  care- 
fully shortly  after  rupture  a  prevesical  swelling  will  generally  be 
detected — symmetric  if  it  is  intraperitoneal,  asymmetric  if  it  is 
extraperitoneal.  A  searcher  introduced  into  the  bladder  may 
locate  the  rupture,  as  evidenced  by  the  pressure  made  by  the 
searcher  against  the  hand  on  the  abdomen.  In  intraperitoneal 
rupture  very  little  urine  can  be  obtained,  the  jet  is  diminished  in 
volume,  with  feeble  pressure  under  the  movements  of  inspiration 
and  expiration.  Rupture  of  the  bladder,  particularly  of  the  intra- 
peritoneal type,  if  allowed  to  go  untreated,  is  likely  to  be  followed 
in  four  or  five  days  by  symptoms  of  general  peritonitis.  One 
hundred  and  seven  cases  of  intraperitoneal  rupture  have  been 
reported,  of  whom  82  died  during  the  first  five  days.  In  those 
cases  in  which  the  rupture  takes  place  extraperitoneally  the 
symptoms  of  urinary  infiltration  are  more  numerous,  and  its 
increase  is  manifested  by  the  extension  of  the  prevesical  swelling 
and  the  tendency  of  the  infiltration  to  extend  in  other  directions. 
More  or  less  pain  in  the  region  of  the  buttocks  is  generall}^  present. 

Rectal  examination  may  be  an  aid  in  diagnosing  urinary  infil- 
tration. It  is  necessary  to  differentiate  this  condition  from  injury 
of  the  kidney,  as  the  latter  may  also  give  rise  to  tenesmus  and 
bloody  urine.  The  searcher,  associated  with  the  rectal  and  abdom- 
inal touch,  should  be  of  considerable  aid  in  making  the  differen- 
tiation. The  prognosis  will  depend  upon  many  different  factors — 
the  nature  of  the  injury  to  other  organs,  the  age  of  the  patient, 
and  many  accompanying  circumstances.  As  a  rule,  the  prognosis 
is  grave. 

Treatment. — The  treatment  must  necessarily  be  modified  to 
suit  the  individual  case.  When  doubt  exists  concerning  rupture 
or  injury  of  the  bladder  within  twenty-four  hours  of  the  time  of 


TOTAL   EXTIRPATION    OF   THE    BLADDER  407 

the  injury,  an  abdominal  incision  should  be  made  and  the  bladder- 
wall  examined.  If  an  intraperitoneal  rupture  has  occurred,  it 
should  be  sewed  up  with  catgut.  The  peritoneum  should  also 
be  united  with  fine  catgut  or  silk,  the  latter  being  used  in  preference 
to  the  catgut  when  there  is  fear  that  the  former  may  be  too  rapidly 
absorbed  before  the  opening  has  united.  An  ununited  opening 
may  give  rise  to  peritonitis.  The  serous  and  muscular  surfaces 
only  should  be  sutured.  The  opening  should  then  be  closed, 
and  a  perineal  section  made  for  drainage  purposes  or  a  retention 
catheter  should  be  put  in  place.  If  an  extraperitoneal  rupture 
exists,  a  suprapubic  incision  may  be  made,  the  condition  of  the 
walls  of  the  bladder  examined,  and  such  after-treatment  pre- 
scribed as  the  needs  of  the  case  may  seem  to  indicate.  If  infil- 
tration has  taken  place,  this  is  manifested  by  the  swelling  about 
the  gluteal  region,  thighs,  perineum,  and  lower  part  of  the  abdo- 
men. In  such  infiltrations  incisions  should  be  made  through 
the  skin  and  cellular  tissue,  and  as  many  drainage-tubes, 
running  in  various  directions,  introduced  as  the  character  and 
number  of  such  infiltrations  require,  in  order  that  the  skin  and 
cellular  tissue  be  drained  as  well  as  possible,  otherwise  trouble- 
some sloughing  will  result;  some  is,  nevertheless,  bound  to  occur 
in  any  case. 

There  is  one  point  to  which  attention  must  again  be  drawn, 
and  that  is  as  to  the  urgent  need  of  performing  early  catheteriza- 
tion in  persons  found  in  an  unconscious  state  from  injury,  drunk- 
enness, or  apoplexy.  In  a  large  series  of  these  cases  studied  by 
the  writers,  overdistention  was  found  to  be  the  principal  pre- 
disposing cause  of  cystitis.  This  series  included  some  cases  of 
unrecognized  rupture  of  the  bladder.  Early  catheterization,  then, 
if  sometimes  performed  on  the  unconscious,  would  reduce  the 
number  of  cases  of  cystitis  due  to  overdistention,  and  would 
occasionally  permit  an  earlier  diagnosis  of  rupture  of  the  bladder 
to  be  made,  thereby  increasing  the  prospects  of  a  favorable  after- 
result. 

TOTAL  EXTIRPATION  OF  THE  BLADDER 

This  operation  is  occasionally  performed  for  extrophy  of  the 
bladder,  as  previously  mentioned,  or  for  the  relief  of  patients 
suffering  from  malignant  diseases  of  the  bladder.     It  necessitates 


408         DIAGNOSIS   AND  TREATMENT    OF    BLADDER    DISEASES 

the  performance  of  a  double  nephrotomy,  or  that  the  ureters  be 
transplanted  into  the  intestine  or  the  loin.  In  transplanting  the 
ureters  care  must  be  used  to  see  that  the  course  of  the  ureter 
is  not  interfered  with,  and  that  no  kinking  results.  The  method 
of  transplanting  or  making  an  anastomosis  with  the  intestine 
has  already  been  referred  to.  The  operation  of  excision  con- 
sists in  making  a  long  incision  in  the  median  line  from  the 
pubes  to  the  umbilicus;  at  right  angles  to  this  incision,  just 
above  the  pubes,  an  incision  is  made  across  each  side  as  far  as 
the  external  border  of  the  recti  muscle,  so  that  the  general  shape 
of  the  incision  is  that  of  the  letter  T.  The  skin,  muscles,  and  peri- 
toneum are  incised;  then  the  bladder  should  be  freed  from  the 
deep  layer  of  the  peritoneum  on  each  side,  in  the  following  manner; 
the  intestine  having  previously  been  pushed  upward,  a  pair  of 
forceps  is  put  on  the  top  of  the  bladder  to  pull  it  above  the  pubes; 
the  peritoneum  is  then  cut  along  the  sides  of  the  bladder,  as  far 
as  the  base  of  the  bladder ;  a  transverse  incision  then  divides  the 
peritoneum,  just  back  of  the  posterior  superior  border  of  the 
prostate ;  the  peritoneum  is  then  stripped  off  the  bottom  of  Douglas' 
cul-de-sac  and  the  posterior  aspect  of  the  prostate.  With  the 
peritoneum  are  detached  the  seminal  vesicles  and  the  extremities 
of  the  vas.  The  bladder  is  now  pulled  forward  on  to  the  pubes, 
and  the  pelvic  peritoneum  is  brought  together  by  a  vertical  suture 
from  the  bottom  of  Douglas'  cul-de-sac  to  the  upper  border  of 
the  abdominal  incision;  the  remainder  of  the  operation  is  extra- 
peritoneal. The  various  ligaments  are  tied  off,  and  the  ureters 
are  cut  through.  If  the  bladder  be  lifted  up  with  considerable 
tension,  the  incision  of  the  ligaments  is  rendered  easier.  The 
urethra  is  then  incised  in  front  of  the  neck  of  the  bladder,  the 
organ  being  pulled  toward  the  umbilicus  for  this  purpose.  The 
bladder  is  then  removed  as  a  complete  sac,  the  cavity  is  then 
drained  and,  if  necessary,  packed. 

HERNIA   OF  THE  BLADDER 

Vesical  hernia  is  generally  associated  with  inguinal  hernia,  and 
manifests  itself,  as  does  the  latter,  by  swelling  in  the  groin.  Very 
rarely  it  happens  that  a  hernia  of  the  bladder  descends  with 
intestinal  hernia  into  the  scrotum.     The  condition  often  remains 


HERNIA  OF  the;  bladder 


409 


unrecognized  until  operation  for  the  relief  of  hernia  is  performed. 
Occasionally  it  is  very  manifest,  as  is  shown  in  the  illustrations 
taken  from  Frisch  and  Zuckerkandl.  If  marked  diminution  in 
the  size  of  the  tumor  is  found  to  take  place  on  urination,  a  diag- 
nosis of  bladder  hernia  can  be  made. 

In  operating  for  the  relief  of  inguinal  hernia,  if  protrusion  of 
the  bladder  is  also  encountered,  it  should  be  freed  from  adhesions 
and  returned  to  its  place  and  the  wound  sutured.  An  attempt 
should  be  made  to  restore  it  to  its  former  position  even  if  all  the 
adhesions  cannot  be  freed.  If  a  vesical  hernia  becomes  strangu- 
lated, it  may  be  necessary  to  open  and  drain.  If  the  bladder 
hernia  has  formed  a  pouch  so  that  urine  that  collects  in  it  cannot 
be  released  from  the  bladder,  it  may  be  necessary  to  also  open  the 
pouch  and  drain.  If  the  bladder  is  wounded  during  the  opera- 
tion for  hernia,  the  incision  should  be  sutured,  the  hernia  of  the 


Fig.  167. — Hernia  of  bladder  (Frisch  and  Zuckerkandl). 


bladder  replaced,  and  drainage  instituted  through  the  suprapubic 
incision  by  the  perineal  route  or  by  a  retention  catheter. 

The  treatment  of  the  case  will  depend  to  a  great  extent  on  the 
individual  circumstances  surrounding  each  case ;  it  may,  however, 
be  summed  up  as  follows :  the  return  of  the  hernial  pouch ;  when 
possible,  the  opening  and  draining  of  the  bladder  pouch,  which 
will  hasten  the  expulsion  of  retained  secretions  that  cannot  other- 
wise be  voided,   together  with   drainage   of  the  bladder,   when 


4IO  DIAGNOSIS   AND    TREATMENT    OF   BLADDER    DISEASES 

necessary,  by  suprapubic  or  perineal  incision.  Resection  of  the 
bladder  for  hernia  followed  by  suture  of  the  organ  has  not  as  yet 
been  demonstrated  to  be  a  successful  operation. 

DIVERTICULA  OF  THE  BLADDER 

These  may  not  in  themselves  give  rise  to  any  characteristic 
symptoms,  whether  they  are  of  the  congenital  or  the  acquired 
variety.  The  use  of  the  cystoscope  and  instrumentation  will 
generally  render  their  diagnosis  comparatively  simple.  Concern- 
ing their  treatment,  if  there  is  no  cystitis  present,  they  can  be 
allowed  to  remain  as  they  are.  If  the  bladder  becomes  infected, 
the  effect  of  irrigations  should  be  observed;  if  such  irrigations 
are  not  sufficient  to  restore  the  bladder  to  a  normal  condition,  it 
may  become  necessary  to  operate  on  the  diverticula.  The  form  of 
operation  required  will  be  indicated  by  the  nature  of  the  diver- 
ticula. A  simple  wall  existing  between  the  diverticula  and  the 
bladder  can  be  removed  by  incision,  and  the  whole  cavity  thrown 
into  one.  Other  forms  of  diverticula  will  require  complete  removal 
and  suturing  of  the  bladder-wall. 

Patent  Urachus.- — A  patent  urachus  may  be  the  seat  of  abscess 
and  sometimes  the  point  of  origin  of  tumors  and  cysts.  The 
cysts  are  generally  retention  in  origin,  according  to  Vaughan,^  who 
has  made  a  careful  study  of  the  matter.  The  different  forms  of 
patent  urachus  are  discussed  under  the  four  headings: 

(i)  The  complete,  in  which  the  duct  is  open  all  the  way,  forming 
a  continuous  communication  between  the  bladder  and  the  out- 
side of  the  body  at  the  navel. 

(2)  The  blind  internal,  in  which  the  navel  remains  closed,  but 
the  duct  communicates  with  the  bladder. 

(3)  The  blind  external,  in  which  the  communication  with  the 
bladder  is  closed,  but  the  navel  end  of  the  duct  remains  open. 

(4)  The  bUnd,  in  which  both  ends  are  closed,  but  the  duct  re- 
mains open  in  the  middle. 

Thirty-two  out  of  fifty  congenital  cases  were  in  men,  the  lesion 
appearing  at  birth  or  soon  after  the  stump  of  the  cord  separated. 
The  acquired  cases,  that  is,  those  in  which  patent  urachus  subse- 

^  "  Patent  Urachus,"  "  Transactions  of  the  American  Surgical  Assoc,"  1905, 
vol.  xxiii. 


.DIVERTICULA    OF   THE    BLADDER 


411 


quently  develops,  may  be  of  any  age,  the  oldest  reported,  accord- 
ing to  Vaughan,  being  seventy-nine.  Symptoms  vary  according 
to  the  condition  present ;  they  may  consist  in  having  urine  appear 
at  the  umbilicus,  or  pus,  or  the  indication  of  formation  of  cysts. 
Patent  urachus  can  be  diagnosed  with  comparative  ease  if  there 
is  an  exudation  of  ous  or  blood  from  the  umbilicus;  if  a  cystic 


Fig.  i68. —  Patent  urachus :  N,  Navel;  Z7,  urachus  (dilated);  B,  bladder  (after  Vaughan). 

formation  exists,  it  may  be  mistaken  for  cysts  due  to  other  causes. 
If  the  umbilicus  opening  is  closed,  it  may  be  diagnosed  from  cysts 
due  to  other  causes  by  instrumental  or  cystoscopic  examination 
of  the  bladder.  Treatment,  when  possible,  consists  of  extirpa- 
tion, closure  of  the  bladder  opening  with  sutures  and  drainage, 
or  in  some  cases  the  slitting  up  of  the  cavity  and  packing  it. 


CHAPTER  XXI 

THE  ANATOMY  OF  THE  PENIS  AND  MALE  URETHRA 

The  penis  is  made  up  of  four  elemental  structures.  These  are 
the  corpora  cavernosa,  the  corpus  spongiosum,  and  the  glans 
penis.  Of  these,  the  corpora  cavernosa  form  the  principal  part. 
They  are  two  cylindric  bodies,  placed  side  by  side,  flattened  at 
their  median  aspect,  and  partly  blended  together  in  the  median 
line  in  the  anterior  portion,  but  separated  posteriorly,  where  they 
branch  out  into  first  bulging  and  then  tapering  masses ;  these  are 
attached  to  the  rami  of  the  pubic  bones,  and  are  known  as  the 
crura  of  the  penis. 

Each  corpus  cavernosum  is  surrounded  b}^  a  thick  and  very 
dense  layer  of  fibrous  connective  tissue  known  as  the  tunica  alhu- 
ginea.  The  tunics  of  the  corpora  blend  more  or  less  in  the  median 
line,  to  form  the  septuvi  pectiniforme,  which  is,  however,  not  a  com- 
plete septum,  since  in  the  anterior  portion  of  the  penis  its  con- 
tinuity is  broken,  so  that  the  substance  of  the  corpora  blends, 
to  a  greater  or  less  extent,  in  the  anterior  portions.  From  the 
interior  of  the  fibrous  envelops  and  from  the  septum  numerous 
lamellae,  bands,  and  cords  composed  of  mingled  fibrous  and 
elastic  connective  tissue  and  of  smooth  muscle  pass  inward  and 
run  through  and  across  the  cavity  in  every  direction,  thus  sub- 
dividing the  corpora  cavernosa  into  many  interstices.  The 
trabeculae  are  larger  and  stronger  near  the  periphery,  and,  con- 
versely, the  spaces  are  larger,  and  have  thinner  walls  near  the  center. 
In  general,  the  long  diameter  of  these  spaces  is  parallel  to  the  long 
axis  of  the  penis.  These  connecting  spaces  are  lined  by  a  layer  of 
endothelial  cells,  and  are  directly  continuous  with  the  veins,  so 
that  they  are  in  reality  dilated,  anastomosing  venous  spaces. 

The  corpora  cavernosa  receive  their  principal  arterial  blood- 
supply  from  the  profunda  penis  arteries,  the  dorsal  artery  of  the 
penis  contributing  a  smaller  amount.  Inside  the  corpora  caver- 
nosa numerous  arteries  are  carried  within  the  trabeculae;    they 

412 


ANATOMY   OF   THE    PENIS   AND   MALE    URETHRA  413 

terminate  in  branches  of  capillary  minuteness,  which  open  directly 
into  the  intratrabecular  spaces  or  the  venous  sinuses.  Some  of 
the  arteries  project  into  the  spaces,  where  they  present  a  peculiar 
contorted  or  curling  aspect,  and  are  therefore  called  the  helicine 
arteries.  The  purpose  of  these  loops  or  coils  is  probably  to  pre- 
vent the  vessels  from  being  torn  when  the  organ  becomes  erect. 
Directly  continuous  with  the  venous  spaces  are  the  veins  which 
convey  the  blood  from  them,  emptying  it  into  two  sets  of  return 
trunks — those  of  the  dorsal  vein  of  the  penis  and  those  of  the 
prostatic  plexus. 

The  inferior  portion  of  the  united  surface  of  the  corpora  caver- 
nosa is  marked  b}^  a  longitudinal  groove  in  which  is  lodged  the 
corpus  spongiosum,  a  cylindric  mass  beginning  at  the  triangular 
ligament  of  the  perineum,  where  it  is  placed  midway  between  the 
crura.  The  posterior  portion  is  enlarged  into  a  bulbous  dilation 
and  extends  forward  as  a  somewhat  tapering  cylinder,  until  it 
reaches  the  anterior  extremity  of  the  corpora  cavernosa,  over 
which  it  expands  into  a  large,  conic  mass,  the  glans  penis. 

Throughout  its  entire  course  the  corpus  spongiosum  incloses 
and  invests  the  male  urethra  and  its  special  coats.  The  structure 
of  the  corpus  spongiosum  is  essentially  the  same  as  that  of  the 
corpora  cavernosa,  but  the  fibrous  framework  is  much  less  dense 
and  the  venous  spaces  are  much  smaller.  These  become  congested 
in  the  erect  state  of  the  organ,  but  never  to  so  marked  a  degree 
as  do  the  sinuses  of  the  corpora  cavernosa.  The  blood-supply  of 
the  corpus  spongiosum  is  derived  from  the  two  lateral  branches 
of  the  internal  pubic,  which  enters  the  body  at  the  bulb  and  ex- 
tends as  far  forward  as  the  glans. 

The  glans  penis  is  a  conic  enlargement  of  the  corpus  spongiosum 
which  covers  over  the  ends  of  the  cavernosa  and  forms  the  anterior 
portion  or  cap  of  the  penis.  It  is  made  up  of  a  still  more  dense 
form  of  erectile  tissue  than  is  the  corpus  spongiosum,  and  is  covered 
in  by  a  thick  mucous  membrane  of  stratified  squamous  epithelium 
which  is  reflected  over  very  numerous  small  papillae  of  the  connec- 
tive tissue,  beneath  which  are  contained  the  special  sense  nerve- 
endings,  the  genital  corpuscles.  The  glans  receives  its  arterial 
supply  from  the  dorsal  artery  of  the  penis,  and  returns  its  venous 
blood  into  the  great  dorsal  vein. 


414  ANATOMY    OF    THE    PENIS    AND    MALE    URETHRA 

The  three  cyHndric  bodies  of  the  penis  are  united  by  somewhat 
dense  encircHng  fibers  of  areolar  connective  tissue,  which  support 
the  vessels,  nerves,  and  lymphatics  of  the  organ.  Outside  the 
encircling  sheet  of  connective  tissue  there  is  a  loose  areolar  Ip-yer 
of  connective  tissue,  devoid  of  fat  and  uniting  the  skin  to  the  penis. 

The  skin  covering  the  penis  is  characterized  by  its  thinness,  its 
freedom  from  fat,  and  its  large  venous  and  lymphatic  supply. 
Its  anterior  portion  is  devoid  of  hair,  and  is  prolonged  over  the 
glans  as  the  foreskin,  or  prepuce,  the  internal  surface  of  which  is 
lined  with  a  mucous  membrane  uniting  the  back  of  the  corona 
with  that  which  covers  the  glans.  About  the  corona  is  situated 
a  ring  of  large  modified  sebaceous  glands  called  the  glands  of 
Tyson.  These  give  rise  to  an  odoriferous  waxy  secretion,  which, 
mixed  with  the  desquamated  epithelial  cells,  forms  the  smegma. 

The  blood-supply  of  the  penis  has  been  sufficiently  described 
elsewhere.  The  h^mphatics  form  a  dense  network  on  the  glans 
and  foreskin,  and  also  surround  the  urethra  in  the  corpus  spongio- 
sum; they  empty  chiefly  into  the  inguinal  lymph-nodes,  but 
some  of  the  deeper  trunks  that  supply  the  corpora  join  with  the 
lymph  tracts  of  the  pelvis. 

The  male  urethra  presents  a  structure  of  considerable  com- 
plexity, and  to  the  physician  who  makes  a  specialty  of  diseases  of 
the  male  genital  organs  its  microscopic  structure  is  of  the  greatest 
possible  importance.  It  extends  from  the  bladder  to  the  end  of 
the  penis,  a  distance  of  about  eight  inches,  varying  according  to 
the  length  of  the  penis  and  the  condition  of  that  organ.  Its  inner 
tube  is  lined  by  a  continuous  epitheHal  covering  and  normally 
its  walls  are  collapsed  and  in  contact,  except  during  the  passage 
of  the  seminal  or  urinary  fluids.  Anatomically  the  urethra  may 
be  divided,  for  purposes  of  description,  into  three  portions — pros- 
tatic, membranous,  and  penile. 

The  prostatic  urethra  is  that  portion  inclosed  in  the  prostate 
gland.  It  is  about  i\  inches  in  length,  and  is  wider  than  either 
of  the  other  two  portions.  At  about  its  center  it  presents  a  dilata- 
tion known  as  the  prostatic  sinus.  The  lining  membrane  is  thrown 
into  longitudinal  folds,  and  is  covered  by  a  transitional  epithelium 
continuous  with  that  of  the  bladder.  A  few  millimeters  from  the 
opening  into  the  bladder  there  is  a  small  triangular  elevation  of 


PLATE  XII 


Ischioeavcrnosus 


a,  The  corpora  cavernosa  of  the  penis:  The  glans  penis  and  the  anterior 
part  of  the  corpus  cavernosum  of  the  urethra  have  been  drawn  aside.  *  = 
Points  which  are  in  contact  when  the  parts  are  in  their  natural  position,  b. 
The  male  urethra  with  the  corpora  cavernosa  of  the  penis,  the  bulbourethral 
glands  and  the  prostate:  The  corpus  cavernosum  of  the  urethra  has_  been 
opened  by  a  longitudinal  incision  in  its  mid-ventral  line.  **  =  Sounds  in  the 
orifices  of  the  bulbourethral  glands  (Sobotta  and  McMurrichl. 


ANATOMY   OF   THE    PENIS   AND   MALE   URETHRA  415 

the  mucous  membrane  known  as  the  verumontanuni;  this  acts  as 
a  valve  that  closes  the  entrance  into  the  bladder  and  so  serves  to 
prevent  return  flow  of  the  semen  during  ejaculation.  On  each 
side  of  the  verumontanum  the  floor  of  the  urethra  is  slightly 
depressed  and  perforated  by  numerous  foramina,  which  are  the 
ducts  of  the  prostate  gland ;  these  discharge  their  viscid  secretion 
into  the  urethra  at  this  point.  Just  anterior  to  the  verumonta- 
num is  the  orifice  of  a  blind  pouch,  the  simis  pocularis,  on  whose 
edges  are  the  slit-like  openings  of  the  common  seminal  or  ejacu- 
latory  ducts.  Into  this  pouch,  as  it  extends  backward  for  about 
half  an  inch,  numerous  tiny  glands  open.  It  is  lined  by  columnar 
epithelium,  and  discharges  its  contents  into  the  urethra.  When 
this  pocket  is  involved  in  inflammatory  disease  of  the  urethra, 
the  condition  does  not  respond  readily  to  treatment  on  account 
of  this  anatomic  structure.  The  walls  of  the  prostatic  urethra 
are  made  up  of  the  firm  tissue  of  the  prostate  gland,  but  at  the 
point  where  the  urethra  unites  with  the  bladder  there  is  a  well- 
developed  circular  band  of  smooth  muscle — the  so-called  "cut 
off  muscle." 

The  membranous  urethra  is  that  portion  situated  between  the 
prostate  gland  and  the  bulb  of  the  corpus  spongiosum.  It  is 
about  three-fourths  of  an  inch  long,  and  its  anterior  part  is  covered 
by  the  bulb  of  the  corpus  spongiosum ;  it  is  the  narrowest  portion 
of  the  urethra  and  is  lined  by  stratified  columnar  epithelium.  Its 
wall  is  made  up  of  a  vascular  erectile  areolar  connective  tissue, 
and  of  encircling  fibers  of  smooth  muscle  that  are  continuous 
with  those  fibers  that  make  up  the  muscular  walls  of  the  bladder. 
These  are  further  augmented  by  the  compressor  urethrae  muscle, 
which  externally  surrounds  the  membranous  portion  of  the  ure- 
thra. Into  the  anterior  portion  of  the  membranous  urethra  enter 
the  ducts  of  Cowper's  glands.  These  are  two  racemose  glands, 
situated  on  each  side  of  the  membranous  urethra,  just  back  of  the 
bulb.  They  are  lined  by  clear  columnar  epithelial  cells,  and  their 
basement  membrane  is  made  up  of  smooth  muscle  and  areolar 
connective  tissue.  They  secrete  a  clear  viscid  substance  which  is 
discharged  into  the  membranous  urethra. 

The  penile  or  spongy  portion  of  the  urethra  is  entirely  inclosed  by 
the  erectile  tissue  of  the  corpus   spongiosum;    it  is  the  longest 


4i6 


ANATOMY  OF  THE  PENIS  AND  MALE  URETHRA 


portion  of  the  canal.      In  cross-section  it  is  seen  as  a  transverse 
slit  running  up  to  the  glans,  where  it  dilates  into  a  spindle-shaped 

chamber  called  the  fossa  nav- 
icularis.  This  opens  on  the 
surface  of  the  glans  by  a 
vertical  slit,  the  meatus  urin- 
arius,  which  is  normally  the 
narrowest  part  of  the  entire 
urethral  canal.  The  penile 
portion  of  the  urethra  is  lined 
by  simple  columnar  epithe- 
lium up  to  the  fossa  navicu- 
laris;  there  the  lining  con- 
sists of  stratified  squamous 
epithelium,  which  is  a  con- 
tinuation of  that  of  the  sur- 
face of  the  glans.  Numerous 
small  tubular  glands  whose 
ducts  open  out  into  the 
epithelial  surface  are  found 
throughout  the  entire  course 
of  the  penile  urethra — these 
are  the  glands  of  Littre 
and  the  lacunae  of  Morgagni. 
They  secrete  a  substance 
that  keeps  the  mucosa  of 
this  portion  of  the  urethra 
moist.  The  walls  of  the 
penile  portion  of  the  urethra 
contain  no  muscle  tissue,  but 
are  made  up  of  the  epithelium  and  of  a  continuation  of  the  con- 
nective tissue  of  the  corpus  spongiosum. 


Fig.  i6g. —  Longitudinal  section  tVirough  the 
urethra,  showing  the  large  lacunae  of  Morgagni 
and  the  small  glands  of  LittrS  (after  H.  Frantz). 


CHAPTER  XXII 

DISEASES  OF  THE  MALE  URETHRA 

URETHRITIS 

Pathology.  —  Urethritis  may,  for  descriptive  purposes,  be 
divided  into  two  forms — the  acute  and  the  chronic;  this  division 
is  capable  of  further  subdivision,  and  of  these  the  catarrhal  and 
the  purulent  forms  are  most  important.  The  condition  is  most 
frequently  due  to  infection  by  the  gonococcus,  and  hence  it  is 
the  gonorrheal  form  with  which  we  are  chiefly  concerned.  In  the 
clinical  consideration  of  this  disease  the  term  urethritis  is  used 
somewhat  generally  to  describe  various  forms  of  inflammation  of 
the  urethral  canal,  the  term  being  applied  to  both  those  cases  in 
which  the  gonococcus  can  and  those  in  which  it  cannot  be  de- 
monstrated. 

Acute  catarrhal  urethritis  results,  as  a  rule,  from  the  irritation 
set  up  by  chemic  substances  excreted  in  the  urine.  The  changes 
produced  by  this  condition  consist  of  a  hyperemia  of  the  blood- 
vessels of  the  mucosa,  usually  with  more  or  less  desquamation 
of  the  urethral  epithelium,  and  a  greater  or  less  degree  of  leuko- 
cytic exudation  and  infiltration.  When  the  condition  is  due  to 
bacterial  activity,  it  is  usually  succeeded  by  the  development  of 
acute  purulent  urethritis,  under  which  heading  these  more  impor- 
tant changes  will  be  discussed.  Owing  to  the  stimulation  of  the 
irritant  that  produced  the  inflammation  hypersecretion  of  mucus 
from  the  urethral  glands  takes  place,  giving  to  the  exudate  a  char 
acteristic  glairy  and  mucoid  character.  When  infection  follows 
catarrhal  urethritis,  particularly  when  such  organisms  as  mem- 
bers of  the  proteus  or  colon  group  are  present,  chronic  inflamma- 
tion may  follow. 

Chronic  catarrhal  urethritis  may  occur  as  a  sequel  to  prolonged 
acute  catarrhal  urethritis,  but,  as  a  rule,  it  more  frequently  fol- 
lows suppurative  and  particularly  gonorrheal  urethritis.     In  these 
cases  it  is  usually  associated  with   stricture  and  with  chronic 
27  417 


4l8  DISEASES    OF   THE    MALE    URETHRA 

inflammation  of  the  mucus-secreting  glands.  These  changes  will 
be  discussed  at  greater  length  under  the  sequels  of  purulent  ure- 
thritis. 

Acute  Purulent  Urethritis. — Acute  purulent  urethritis  may  de- 
velop as  the  result  of  infection  of  the  urethra  by  any  virulent 
organism,  or  it  may  follow  the  application  of  an  irritant  to  the 
urethra  for  medicinal  purposes  or  the  voiding  of  irritating  sub- 
stances in  the  urine.  The  gonococcus  is  by  far  the  most  frequent 
cause  of  urethritis,  however,  as  seen  by  the  practitioner.  In  the 
discussion  of  the  pathology  of  urethritis,  therefore,  the  aim  will 
be  to  adhere  to  the  changes  that  occur  in  this  most  frequent 
specific  type  of  the  disease,  it  being  understood  that  the  anatomic 
changes  that  take  place  in  all  the  infectious  forms  are  practically 
alike,  varying  in  intensity  according  to  the  virulence  of  the  infect- 
ing organisms. 

Bacteriology. — For  a  proper  understanding  of  the  changes  that 
take  place  in  gonorrheal  urethritis  it  is  necessary  first  to  consider 
briefly  the  biologic  characteristics  of  the  gonococcus,  for  it  is  by 
certain  of  these  quahties  that  the  virulence  of  the  disease  and  its 
treatment  are  considerably  modified.  Perhaps  the  most  impor- 
tant of  the  biologic  characteristics  of  the  gonococcus  is  its  almost 
strictly  parasitic  nature,  as  a  result  of  which  the  organism  cannot 
live  for  any  considerable  length  of  time  except  in  living  animal 
tissues  or  in  carefully  prepared  artificial  media  that  closely  simu- 
late them.  As  a  further  result  of  this  parasitic  character,  which 
is  further  confined  to  man  and  the  higher  apes,  gonorrhea  is  trans- 
mitted almost  always  directly  from  subject  to  subject.  The 
organism  soon  dies  when  out  of  the  body  even  when  present  in 
moist  discharges  on  infected  clothing,  so  that  cases  of  secondary 
infection  by  this  means  are  probably  rare.  Nevertheless  this 
mode  of  infection  may  be  sometimes  held  responsible  for  the 
epidemics  of  gonorrhea  seen  in  children's  hospitals.  A  further 
characteristic  of  the  organism  is  its  predilection  for  the  mucous 
and  serous  surfaces,  although  hemic  infection,  as  in  gonorrheal 
endocarditis  or  septicemia,  occasionally  takes  place.  No  toxins 
or  antitoxic  bodies  are  formed  by  the  gonococcus ;  and  immunity, 
either  natural  or  acquired,  in  man  is  a  most  unusual  condition. 
This  statement  must,  however,  be  somewhat  modified  by  the  fact 


URETHRITIS  419 

that,  under  certain  circumstances,  prolonged  exposure  to  a  defi- 
nite strain  or  culture  of  the  organism  confers  a  degree  of  resistance 
toward  it,  as  is  well  shown  in  certain  cases  of  gleet.  This  pecu- 
liarity is  noticeable  in  cases  in  which,  infection  having  taken  place, 
continued  exposure  does  not  result  in  the  breaking  out  of  the 
infection  in  one  or  the  other,  although  either  subject  would  be 
capable  of  transmitting  it  to  a  third  person;  if,  however,  a  fresh 
infection  is  introduced,  active  acute  inflammatory  changes  develop. 

A  predisposition  to  gonorrheal  infection  undoubtedly  exists 
in  many  cases,  but,  in  most  instances,  this  is  a  direct  result  of 
conditions  facilitating  primary  inoculation,  such  as,  for  example, 
abrasion  or  fissure  of  the  exposed  epithelial  surfaces;  simple 
inflammatory  conditions  induced  by  a  highly  acid  urine  or  by  the 
excretion  of  alcohol  and  other  chemic  irritants. 

Mode  of  Infection. — Under  normal  conditions  the  epithelium 
of  the  fossa  navicularis,  so  capable  of  obviating  bacterial  infec- 
tion, does  not  permit  infection  with  the  gonococcus  to  take  place 
in  this  portion  of  the  urethra.  If,  however,  from  any  cause  this 
surface  is  eroded  or  fissured,  infection  quickly  follows.  Close 
clinical  observation  apparently  demonstrates  that  in  many  cases 
the  gonococcus  may  remain  in  the  fossa  navicularis  for  a  consid- 
erable period  of  time,  and  may  even  reproduce  in  this  portion  of 
the  tract,  without  exciting  marked  inflammatory  reaction.  If, 
however,  the  organism  gains  access  to  the  pendulous  portion  of 
the  urethra,  either  by  direct  extension  from  the  fossa  navicularis 
or  by  being  drawn  backward  by  the  aspiratory  action  said  to  fol- 
low relaxation  of  the  bladder  or  of  the  extrusor  muscle,  acute 
inflammatory  reaction  almost  immediately  takes  place.  These 
facts  have  been  amply  proved  by  the  experimental  inoculations  of 
Finger,  who  showed  that  gonococci  will  not  penetrate  the  healthy 
squamous  epithelium  of  the  fossa  navicularis  under  normal  con- 
ditions, although  infection  quickly  follows  the  implantation  of 
infectious  material  on  the  columnar  epithelium  of  the  pendulous 
portion. 

Pathologic  Anatomy. — Finger  found  that  three  days  after 
infection  the  mucous  membrane  was  covered  with  a  copious 
purulent  secretion  and  that  the  epithelial  layer  was  extensively 
infiltrated  with  pus-cells,   which,   on  examination,   showed  that 


420 


DISEASES    OF   THE    MALE    URETHRA 


abundant  gonococci  were  present.  The  lumen  of  the  urethra 
contained  quantities  of  mucus  rich  in  gonococci.  The  inflamma- 
tory reaction  had  extended  into  the  tissues  of  the  corpus  spongio- 
sum, which  showed  also  purulent  infiltration  and  round-celled 
proliferation,  although  gonococci  were  but  rarely  found  in  the 
deeper  layers. 

The  glands  of  Littre  become  extensively  involved,  the  infection 
apparentlv  traversing  the  duct  of  the  gland  down  to  the  deep- 
lying  acini,  where  local  inflammation,  often  terminating  in  abscess 
formation,  takes  place.  Later  marked  desquamation  of  the 
urethral  epithelium  occurs,  and  the  mucous  membrane,  as  seen 

through  the  urethral  coat, 

d  a 


f^«s5 


mmm^ 


/V's 


appears  studded  with 
minute  ulcerations,  usu- 
ally situated  about  the 
openings  of  the  urethral 
glands.  Thrombosis  of 
many  of  the  submucous 
blood-vessels  takes  place, 
and  may  extend  into  the 
erectile  sinuses  of  the  cor- 
pus spongiosum  or  even 
into  those  of  the  corpora 
cavernosa,  giving  rise  to 
chordee,  which  is  due  to  the 
irregular  distention  of  the 
erectile  spaces  when  the 
penis  becomes  engorged. 
In  a  certain  number  of  cases  of  acute  urethritis  the  infection 
may  not  extend  to  a  point  back  of  the  pendulous  urethra,  although 
from  anatomic  researches,  the  writers  are  convinced  that,  as  a 
rule,  the  entire  channel  finally  becomes  more  or  less  involved. 
In  favorable  cases  healing  may  take  place  by  an  absorption  of  the 
inflammatory  exudate,  the  epithehum  reforming,  covering  the 
excoriated  areas  with  a  layer  of  new  epithelial  cells  that  are  no 
longer  columnar,  but  of  the  simple  squamous  type.  Inevitably, 
cicatrices  of  greater  or  less  degree  are  formed  in  the  submucous 
connective  tissues  following  the  absorption  of  the  inflammatory 


Fig.  I/O.— Acute  gonorrheal  urethritis  involving 
the  pendulous  urethra  ;  eight  days  after  infection  :  A, 
Urethra ;  B,  desquamated  epithelial  cells  ;  C,  body  of 
a  gland  of  Littre  ;  D,  inflammatory  infiltration  of  tis- 
sues about  urethra. 


URETHRITIS  421 

exudate,  resulting  in  conditions  that  will  be  discussed  further  on 
under  the  head  of  Stricture. 

One  of  the  most  frequent  sequels  of  acute  specific  urethritis  is 
abscess  formation  in  one  or  more  of  the  glands  of  Littre.  The 
duct  may  become  occluded,  thus  tending  to  localize  the  process, 
whereas  the  exudate  in  other  portions  of  the  urethra  may  entirely 
disappear.  Acute  reinfection  may  follow  the  rupture  of  such  an 
abscess,  or,  in  a  certain  number  of  cases,  rupture  through  the 
capsule  of  the  corpus  spongiosum  and  external  drainage,  with 
the  formation  of  urinary  fistula,  may  follow.  There  can  be  no 
question  but  that  many  cases  of  reinfection  follow  this  autoinocu- 
lation  in  what  are  apparently  cured  cases  of  gonorrhea. 


Fig.  171. — Chronic  stricture  of  the  posterior  urethra  showing  granulomatous  ijiasses  pro- 
jecting into  the  channel  and  explaining  the  persistence  of  urethral  discharge  in  these  cases. 
A,  Urethra;  B,  granulomatous  masses  projecting  into  urethra;  C,  scar  tissue  formed  about 
urethra  as  a  result  of  chronic  inflammation. 

When  the  infection  extends  into  the  posterior  urethra,  an 
extension  may  occur  from  the  membranous  portion  into  the  glands 
of  Cowper  and  into  the  prostatic  urethra,  through  the  ducts  of 
the  prostate  gland  into  the  acini,  where  suppurative  prostatitis 
may  be  set  up.  Similarly,  the  infection  may  involve  the  sinus 
pocularis,  and,  through  the  ejaculatory  ducts,  the  vas  and  seminal 
vesicles,  in  this  way  often  reaching  the  epididymis  and  testicle. 
Diffuse  abscess  formation  may  follow  this  extensive  area  of  in- 
fected mucous  membrane,  and  occasionally  terminate  in  gangrene 
involving  the  entire  penis.  It  should  be  remembered  that  the 
extension  and  character  of  the  later  anatomic  changes  are  largely 
dependent  on   secondary  infection,   and  in   long-standing  cases 


422  DISEASES    OF    THE    MALE    URETHRA 

the  gonococcus  may  even  disappear  entirely,  having  apparently 
been  superseded  by  secondary  organisms,  chiefly  of  the  proteus 
and  colon  varieties. 

Strictures  of  the  urethra  are  among  the  more  frequent  compli- 
cations of  gonorrheal  urethritis.  They  may  occur  in  any  portion 
of  the  tract,  although  in  the  writers'  experience  they  have  been 
found  to  occur  most  often  in  the  membranous  urethra.  They  result 
from  the  hyperplasia  of  the  submucous  connective  tissue  that 
follows  the  acute  inflammatory  changes,  or  that  ensues  as  the 
result  of  phvsiologic  attempts  at  repair  where  loss  of  tissue,  as 
from  abscess  formation  or  thrombosis  with  necrosis,  has  taken 
place.  If  this  occurs  about  or  near  the  urethra,  more  or  less 
obstruction  inevitably  follows,  the  extent  of  which  depends  entirely 
on  the  degree  and  location  of  the  scar  tissue.  The  epithelium 
covering  the  urethral  surface  may  be  entirely  absent,  or,  if  present, 
is  of  the  simple  squamous  and  atypical  variety. 

When  these  obstructions  to  the  urethra  exist,  proper  drainage 
is  no  longer  possible,  and  chronic  inflammatory  exudation  almost 
always  follows,  giving  rise  to  the  discharge  of  a  thin,  watery 
secretion  that  contains  a  few  pus-cells,  desquamated  epithelium, 
and,  in  an  acute  exacerbation  of  the  inflammation,  blood-cells  and 
pus  in  larger  quantities.  This  exudate  is  usually  rich  in  bacterial 
growth,  and  is  more  or  less  highly  infectious,  although  the  gonococ- 
cus itself  may  be  absent  from  it.  It  may  be  remembered  that 
cicatrization  of  greater  or  less  extent  occurs  in  all  cases  where 
loss  of  tissue  has  taken  place  or  inflammation  of  long  standing 
existed ;  but  the  degree  of  urethral  strictur  that  results  is  depen- 
dent not  so  much  on  the  extent  of  this  process  as  on  its  location. 
Extension  of  the  inflammatory  process  to  the  bladder  has  been 
discussed  under  the  head  of  Cystitis. 

Symptoms  of  Urethritis 
It  is  customary  at  the  present  time  to  make  a  classification  of 
the  disease  according  to  whether  the  inflammatory  condition 
extends  beyond  the  bulbomembranous  juncture  or  remains  en- 
tirely within  the  pendulous  urethra,  two  varieties  being  named — 
anterior  and  posterior  urethritis.  Such  inflammatory  conditions 
may  be  either  acute  or  chronic.     Thus  we  have  acute  anterior  and 


URETHRITIS  423 

acute  posterior  urethritis,  and  chronic  anterior  and  chronic  pos- 
terior urethritis. 

When  acute  inflammation  exists  in  the  posterior  urethra,  the 
anterior  urethra,  as  a  rule,  is  also  involved ;  therefore  when  acute 
posterior  urethritis  is  present,  a  general  urethritis  may  ordinarily 
be  said  to  exist.  It  may  easily  be  demonstrated  that  in  a  large 
majority  of  cases — probably  in  all — urethritis  involves  the  pos- 
terior urethra.  It  is  the  custom  with  many,  however,  to  consider 
clinically  as  either  acute  or  chronic  anterior  urethritis  those  cases 
in  which  the  symptoms  are  not  urgent  enough  to  indicate  much 
involvement  of  the  posterior  urethra. 

Sjmiptoms  and  Course  of  Acute  Anterior  Urethritis.— The  period 
of  incubation  after  infection  has  taken  place  and  before  any 
marked  discharge  occurs  from  the  anterior  urethra  is  from  one  to 
six  days.  During  this  period  no  clinical  symptoms  of  which  the 
individual  is  cognizant  may  be  manifest,  or  there  is  a  slight 
burning  sensation,  an  itching,  or  a  feeling  of  moisture.  The  first 
discharge  that  appears  is  mucous  in  character;  later  it  becomes 
mucopurulent,  in  a  few  days  more  frankly  purulent,  and  occa- 
sionally bloody.  Ordinarily  there  will  be  considerable  pain  and 
burning  on  micturition;  the  mucous  membrane  and  the  meatus 
become  swollen;  micturition  increases  in  frequency,  and  painful 
erections  occur,  particularly  at  night;  attacks  of  chordee  are 
usualh"  frequent  and  extremely  painful,  and  the  acute  stage  of 
urethritis,  generally  of  gonorrheal  origin,  may  now  be  said  to  be 
fully  established. 

After  a  period  whose  length  depends,  among  other  things,  on 
the  constitution  of  the  individual  and  on  the  treatment  instituted, 
the  discharge  diminishes.  It  is,  as  a  rule,  more  profuse  in  the 
morning  than  at  night,  and  subsequently  becomes  mucopurulent  in 
character.  Ordinarily,  in  untreated  cases,  the  change  from  the 
markedly  purulent  to  the  mucopurulent  character  takes  place  in 
from  the  third  to  the  fourth  week.  After  the  discharge  has  be- 
come mucopurulent  it  gradualh^  diminishes  in  quantity  and 
eventually  disappears;  usually,  in  cases  that  do  well,  this  oc- 
curs in  from  four  to  eight  weeks.  Relapses,  however,  are  very 
likely  to  occur,  and  a  subacute  condition  may  be  brought  about 
in  which  a  somewhat  profuse  mucopurulent  discharge  that  may 


424  DISEASES    OF    THE    MALE    URETHRA 

remain  for  weeks  and  months  may  be  present.  Or,  what  is  still 
more  frequent,  a  single  drop  of  discharge  may  be  emitted  in  the 
morning;  this  is  indicative  of  that  condition  of  the  mucous  mem- 
brane of  the  urethra  that  it  has  been  the  custom,  in  the  past,  to 
designate  as  gleet — in  other  words,  a  chronic  inflammatory  con- 
dition exists. 

Symptoms  of  Chronic  Anterior  Urethritis. — The  general  symp- 
tom, then,  of  chronic  anterior  urethritis  is  the  persistence,  for 
many  weeks  and  months  after  the  acute  inflammatory  condition 
has  passed  away,  of  a  mucopurulent  discharge  of  the  morning- 
drop  variety  previously  mentioned,  or  of  the  appearance  of  a 
large  number  of  shreds  from  the  anterior  urethra.  This  inflam- 
matory state  may  depend  on  several  causes,  combined  or  indi- 
vidual, such  as  unhealed  erosions,  granulomata  (so-called  softs 
strictures),  or  infection  of  some  of  the  urethral  glands. 

S3anptoms  of  Acute  Posterior  Urethritis. — The  clinical  symp- 
toms believed  to  be  diagnostic  of  acute  posterior  urethritis  are 
frequent  micturition  at  night,  severe  tenesmus,  often  a  marked 
diminution  of  the  discharge  from  the  anterior  urethra,  bloody 
urine,  occasional  drops  of  blood  exuding  from  the  meatus,  pain 
at  the  end  of  the  penis,  more  or  less  uneasiness  in  the  perineum  or 
rectum,  and  generally  some  rise  in  temperature. 

Symptoms  of  Chronic  Posterior  Urethritis. — This  condition  is 
frequently  associated  with  chronic  anterior  urethritis  and  also 
with  chronic  prostatitis,  in  either  of  which  conditions  the  symp- 
toms indicative  of  the  complicating  disease  would  naturally  be 
expected  to  be  present.  When  not  associated  with  the  conditions 
mentioned,  its  most  frequent  symptoms  are  increased  frequency 
of  micturition  at  night,  uneasy  sensations  at  the  end  of  the  penis, 
in  the  perineum,  or  in  the  rectum,  a  feeling  of  moisture,  a  burning 
sensation  after  urination,  pain  in  coitus,  or  indications  of  sexual 
neurasthenia. 

Diagnosis 

Recently  much  exhaustive  work  has  been  done  to  devise  vari- 
ous methods  for  the  more  accurate  diagnosis  of  the  conditions 
previously  mentioned.      Hugh   Young,'    under  the   title   of  the 

^  "  Johns  Hopkins  Hospital  Report,"  1906. 


URETHRITIS  425 

"Seven-glass  Test,"  has  made  an  investigation  of  the  various 
glass  tests  that  are  in  vogue,  and  has  a  modification  of  his  own, 
which  is  as  follows:  He  uses  in  this  test  a  urethral  irrigation  tube 
made  of  glass,  with  a  rubber  cup  made  from  half  a  small  ball  at  a 
point  about  ten  centimeters  from  the  urethral  end.  "The  patient 
is  instructed  to  compress  the  urethra  between  the  thumb  and 
finger  far  back  at  the  root  of  the  penis  (at  the  suspensory  liga- 
ment) ;  the  irrigating  tube  is  then  slowly  inserted,  with  the  water 
running,  up  to  the  point  of  compression  (suspensory  ligament), 
and  the  fluid  escaping  is  caught  in  two  glasses,  the  first  containing 
shreds,  if  any  be  present,  and  the  second  is  clear  (showing  through 
cleansing).  Then  the  patient's  fingers  are  removed,  and  the  tube 
carried  back  as  far  as  the  deeper  part  of  the  bulbous  urethra,  the 
urine  again  being  caught  in  two  glasses,  the  first  containing  shreds 
from  the  bulbous  urethra  and  the  second  is  clear  as  before. 

"The  patient  then  voids  his  urine  in  three  glasses,  as  in  Koll- 
mann's  test. 

"Besides  being  far  simpler,  owing  to  the  use  of  the  lavage  tube 
and  cup  in  place  of  a  catheter,  the  differentiation  of  the  pendulous 
and  bulbous  portions  of  the  urethra  afforded  has  proved  not  only 
of  considerable  interest,  but  often  of  great  importance  in  locating 
the  lesion,  and  directing  the  character  and  extent  of  treatment 
necessary." 

The  Kollmann  test  referred  to  consists  in  collecting  the  urine  in 
three  glasses  after  the  anterior  urethra  has  been  irrigated  and  the 
washings  caught  in  two  glasses. 

We  have  already,  in  the  chapter  on  the  General  Examination 
of  the  Patient  (page  31)  referred  to  some  of  the  glass  tests  now 
commonly  used  for  the  purpose  of  diagnosing  what  part  of  the 
urethral  canal  is  involved  by  the  inflammatory  process.  When 
the  urethra  is  in  a  state  of  very  acute  inflammation,  with  a  very 
profuse  yellowish  discharge  from  the  meatus,  it  is  unwise  to  wash 
out  the  anterior  urethra  for  the  purpose  of  diagnosis  through  any 
instrument  whatever,  w^hether  the  instrument  be  so  long  that  it 
will  extend  to  the  region  of  the  bulb,  or  whether  a  short  nozzle 
alone  is  used.  For  any  degree  of  discharge  less  than  the  very  acute 
one  just  mentioned  we  have  found  the  very  small  olive-pointed 
gum  catheter   the  most  useful.     It   should   be  so   small   that  it 


426  DISEASES    OE    THE    MALE    URETHRA 

will  not  occlude  the  meatus  to  such  an  extent,  but  there  will 
be  a  free  flow  of  the  fluid  out  from  the  meatus  along  the  side  of 
the  catheter.  It  should  be  introduced  with  the  utmost  gentleness 
as  far  as  the  region  of  the  bulb,  and  four  to  six  ounces  of  normal 
salt  solution  should  be  injected  through  it  with  as  little  force  as 
possible.  The  water  should  be  allowed  to  run  as  the  instrument 
is  removed  from  the  urethra.  The  washings  can  be  collected  in 
glasses,  as  in  the  method  of  Kollmann  or  Young.  The  patient 
should  then  be  allowed  to  urinate  in  three  separate  glasses.  If 
the  urine  is  clear  in  all  three,  it  will  be  fairly  good  evidence 
that  no  acute  inflammatory  process  at  least  exists  beyond  the 
compressor  urethrae  muscle.  If  the  urine  is  cloudy  in  the  first 
glass,  or  contains  shreds  in  the  first  glass,  it  will  indicate  that  the 
posterior  urethra  is  affected,  and  that  an  acute  posterior  urethritis, 
with  or  without  a  prostatitis,  exists.  If  all  three  glasses  are  cloudy, 
it  will  indicate  that  a  cystitis  or  some  inflammatory  lesion  beyond 
the  compressor  urethrae  muscle  exists.  If  the  first  glass  is  cloudy, 
the  second  glass  is  clear,  and  some  slight  cloudiness  is  present 
in  the  third  glass,  it  will  probably  indicate  some  inflammatory 
condition  of  the  prostate,  the  discharge  from  which  is  squeezed 
out  by  the  contraction  of  the  muscular  fibers  at  the  end  of  urina- 
tion. 

Concerning  the  diagnosis  of  chronic  urethritis,  if  the  patient 
complains  of  a  morning  drop,  or  that  he  has  shreds  in  the  urine, 
the  anterior  urethra  should  be  washed  out  in  one  of  the  ways 
suggested,  and  if  no  shreds  are  found  in  the  three  glasses  passed, 
it  is  very  good  evidence  that  the  shreds  do  not  come  from  the 
posterior  urethra  or  the  prostate.  If,  after  washing  out  the 
anterior  urethra,  shreds  are  found  in  the  first  glass,  it  indicates 
that  they  come  from  the  posterior  urethra  or  the  prostate.  If  the 
second  glass  is  clear  and  shreds  are  found  in  the  third  glass,  it 
would  indicate  that  they  came  from  the  prostate.  The  character 
of  the  shreds  also  is  somewhat  of  an  indication  as  to  the  place 
from  which  they  originate.  The  long  fluffy  shreds  are  ordinarily 
from  the  anterior  urethra;  the  small  hammer-shaped  shreds  from 
the  prostate. 

The  diagnosis  of  chronic  anterior  urethritis,  as  previously 
mentioned,  and  its  nature  can  be  made  out  by  direct  inspection 


URETHRITIS 


427 


through  an  endoscope,  by  the  use  of  the  bougie  a  boule  of  varying 
sizes,  by  the  sensation  to  the  touch  through  the  passage  of  an  oHve- 
pointed  bougie.  It  generahy  depends  upon  a  granuloma,  that 
is,  an  inflammatory  infiltration,  or  the  involvement  of  some  of  the 
glands  of  Littre  or  the  crypts  of  Morgagni.  Almost  all  cases  of 
chronic  anterior  urethritis  are  associated  with  chronic  posterior 
urethritis  to  a  greater  or  less  extent. 

The  diagnosis  of  chronic  posterior  urethritis,  in  addition  to  the 
information  furnished  by  the  various  glass  tests  mentioned,  can 
be  aided  by  the  passage  into  the  bladder  of  an  olive-pointed  bougie 
for  the  purpose  of  observing  whether  a  stricture  may  be  present 
or  not.  The  posterior  urethra  may  also  be  observed  under  direct 
inspection  through  a  long  endoscopic  tube,  and  the  appearance  of 
the  colliculus  should  be  particularly  noted.  In  addition  to  this, 
information  is  afforded  by  examination  with  a  steel  instrument 
in  the  bladder  and  the  finger  in  the  rectum.  The  diagnosis  of 
prostatitis,  which  almost  always  accompanies  posterior  urethritis, 
is  referred  to*  in  the  chapter  dealing  with  Diseases  of  the  Pros- 
tate. It  is  hardly  necessary  to  state  in  detail  here  the  various 
causes  besides  the  gonococcus  which  may  give  rise  to  the  urethral 
discharge.  It  may  be  associated  with,  or  follow,  fevers,  it  may 
be  due  to  stricture,  calculi,  the  presence  of  parasites,  and  various 
other  organisms,  such  as  the  pneumococcus,  it  mav  be  traumatic, 
or  associated  with  gout  or  rheumatism.  The  secretions  should  be 
examined  microscopically  before  any  positive  diagnosis  can  be 
made.  The  Gram  stain  will  demonstrate  the  gonococcus  if  present 
in  the  secretion  in  the  vast  majority  of  cases.  Culture  tests  for 
the  gonococcus  we  have  found  to  be  too  uncertain  for  routine 
use. 

For  further  information  concerning  details  of  diagnosis  the 
reader  is  referred  to  the  chapter  on  Examination  of  Patients  and 
Examination  of  Exudates. 

Treatment  of  Non-gonorrheal  Urethritis 

The  treatment  of  the  various  forms  of  non-gonorrheal  urethritis 
necessarily  is  the  treatment  of  the  condition  which  is  the  causa- 
tive factor  of  the  case.  If  a  slight  discharge  is  due  to  a  stricture, 
dilatation  of  the  stricture  and  the  proper  treatment  will  cure  the 


428  DISEASES    Olf   THE   MALE    URETHRA 

discharge.  If  due  to  irregularities  in  the  diet,  proper  hygienic 
measures  should  be  executed.  A  discharge  occasionally  seen, 
in  which  no  gonococci  can  be  found  by  the  microscope,  but  which 
is  due  to  infection  with  simple  pus  micro-organisms,  should  be 
differentiated  from  a  discharge  of  similar  general  appearance  due 
to  irritation  of  some  previous  existing  chronic  lesion  of  the  urethra. 
If  the  latter  is  not  present  and  the  discharge  persists,  local  treat- 
ment by  irrigation  with  the  Ultzmann  injection,  or  nitrate  of  sil- 
ver I  :  10,000,  used  three  times  weekly,  should  be  instituted.  Such 
discharges  ordinarily  quickly  stop  under  the  appropriate  treatment. 

The  Abortive  Treatment  op  Urethritis 
Before  entering  into  a  discussion  as  to  the  proper  treatment  of 
acute  anterior  urethritis,  the  methods  now  in  use  for  aborting  a 
threatened  attack  of  the  disease  must  be  considered.  Various 
lines  of  treatment  intended  to  serve  this  purpose  have  been  sug- 
gested and  tried  for  many  years  past,  but  too  many  factors  had 
to  be  considered  to  render  statistics  as  to  the  benefit  to  be  derived 
from  certain  procedures  of  any  value. 

The  following  method  has  for  many  years  past  been  occasion- 
ally used  by  the  writers.  Recently  we  have  learned  of  a  method 
that  is  somewhat  popular  in  Germany;  for  the  description  of 
this  we  are  indebted  to  Dr.  Henry  H.  Morton,  of  Brooklyn,  N.  Y. 
Authors'  Method. — If  possible,  before  the  gonococci  have  in- 
vaded the  urethra  and  before  the  discharge  has  become  frankly 
purulent,  it  is  the  writers'  custom,  in  certain  cases,  to  inject  as 
large  a  quantity  of  glycerin  as  possible  into  the  anterior  urethra, 
compressing  the  meatus;  the  latter  is  then  allowed  to  open,  and 
a  small  pledget  of  cotton  wrapped  about  the  end  of  a  wooden 
applicator,  and  moistened  with  silver  nitrate  solution  of  the 
strength  of  ten  grains  to  the  ounce,  is  introduced  through  the 
meatus  and  the  outer  two  or  three  inches  of  the  urethra 
painted.  This  application  should  not  be  made  through  an 
endoscope,  for,  in  the  writers'  experience,  the  endoscopic 
tube  proves  irritating  to  the  urethra.  Under  ordinary  circum- 
stances, the  application  should  not  extend  be3^ond  the  first  two 
or  three  inches  of  the  urethra.  The  active  inflammation  set 
up  by  the  silver  nitrate   should.be  counteracted   externally  by 


URETHRITIS  .        429 

applying  cloths  wrung  out  of  hot  water,  and  internally  by  the 
administration  of  potassium  bicarbonate  and  hyoscyamus,  which 
will  render  the  urine  unirritating.  Not  more  than  one  appUca- 
tion  should  be  made  daily,  and  if,  after  three  applications,  no 
beneficial  results  ensue,  the  treatment  should  be  discontinued.  If 
good  results  are  apparent,  the  treatment  should  be  continued  at 
gradually  increasing  intervals  until  six  or  eight  applications  in 
all  have  been  made.  Clinically,  in  the  writers'  experience,  this 
method  seems  most  useful  in  cases  of  relapsing  acute  urethritis  in 
which  a  chronic  inflammatory  condition  has  previously  existed. 

German  Method. — If  the  patient  is  seen  in  the  first  three  days 
before  the  discharge  is  active,  and  the  microscope  shows  the  pres- 
ence of  epithelial  cells  and  leukocytes  together  with  the  gonococci, 
most  of  the  latter  being  extracellular,  the  following  procedure 
may  be  adopted  in  an  effort  to  abort  the  disease.  If,  however, 
the  gonococci  are  very  abundant  and  intracellular,  the  method  is 
contraindicated. 

A  microscopic  examination  of  the  secretion  from  the  meatus 
will  demonstrate  whether  or  not  an  attempt  at  aborting  the 
disease  should  be  made  by  this  method.  When  the  effort  is  to 
be  made,  this  is  best  done  by  irrigating  the  entire  anterior  urethra 
with  a  freshly  made  solution  of  albargin,  i  :  1000.  Occasionally, 
in  such  cases,  the  patient  is  also  directed  to  repeat  the  injection 
himself  three  or  four  times  daily.  Each  time  that  the  albargin 
is  used  a  fresh  solution  should  be  made ;  for  this  purpose  the  albar- 
gin tablets  are  most  convenient.  If,  after  five  or  six  days,  a  cure 
seems  to  be  established,  a  provocative  injection  of  silver  nitrate 
may  be  used  and  any  discharge  that  appears  afterward  examined 
to  see  if  gonococci  are  still  present.  If  they  are  found  to  persist, 
the  abortive  treatment  may  be  considered  to  have  been  a  failure. 
If,  as  the  result  of  the  abortive  treatment,  pus  still  appears  and 
the  gonococci  have  disappeared  after  five  or  six  days,  the  albargin 
irrigation  should  be  discontinued  and  irrigations  of  potassium 
permanganate  substituted. 

In  addition  to  the  local  abortive  treatment,  the  originator  of 
the  foregoing  method  also  prescribes  gonosan  internally.  There 
is  danger,  in  almost  all  forms  of  abortive  treatment,  of  giving  rise 
to  epididymitis,  and  also  to  other  complications  of  urethritis. 


430  DISEASES    OF    THE    MALE    URETHRA 

From  a  studv  of  fig.  i6o,  which  portrays  a  patient  who  died  of 
pneumonia  while  suffering  at  the  same  time  from  an  acute  ure- 
thritis, it  will  be  seen  that  the  inflammatory  condition  extended 
into  the  follicles  of  the  urethra  and  the  glands  of  Littre.  From  a 
pathologic  point  of  view,  therefore,  it  would  be  impossible  to 
cure  a  urethritis  by  means  alone  of  local  injections  and  irrigations 
confined  to  the  anterior  urethra;  nevertheless  this  early  local 
treatment,  unaccompanied  by  the  use  of  any  other  remedial  meas- 
ure, is  still  very  popular. 

As  the  result  of  the  writers'  pathologic  investigations  and  clini- 
cal experience,  amply  substantiated  by  some  of  their  associates, 
they  are  convinced  that  it  is  better  to  postpone  the  active  local 
treatment  of  urethritis  until  after  the  acute  stage  has  passed  and 
the  discharge  first  becomes  mucopurulent ;  this  is  generally  about 
the  fourth  to  the  sixth  week  after  the  onset  of  the  disease.  It 
may  be  said,  however,  that  many  conscientious  and  able  surgeons 
hold  a  different  view  as  regards  the  treatment  of  acute  anterior 
urethritis;  in  acute  posterior  urethritis,  on  the  other  hand,  almost 
all  agree  that  active  local  measures  should  not  be  undertaken. 
Those  who  favor  the  early  local  treatment  do  not  directly  dispute 
the  fact  that  most,  if  not  all,  cases  of  anterior  urethritis  are  ac- 
companied by  coincident  posterior  urethritis;  nevertheless  they 
differentiate  clinically,  more  than  pathologically,  between  the 
two  conditions,  diagnosing  as  acute  anterior  urethritis  those  cases 
in  which  painful  and  increased  frequency  of  micturition  at  night, 
and  various  other  symptoms  that  are  characteristic  of  acute 
posterior  urethritis,  are  absent.  In  outlining  any  early  local 
treatment  to  be  pursued  for  acute  urethritis,  therefore,  that 
method  of  local  treatment  that  appeals  most  strongly  to  the 
writers  has  been  described,  although,  as  previously  stated,  they 
consider  is  wiser  to  postpone  all  local  treatment  until  after  the 
acute  stage  has  passed. 

Treatment  of  Acute  Anterior  Urethritis 
The  medicinal  treatment  of  acute  urethritis  has  been  so  exten- 
sively dealt  with  that  most  physicians  are  famiUar  with  it.     If 
no  attempt  is  made  to  abort  the  disease  and  the  patient  is  seen  at 
the  beginning  of  the  attack  or  when  the  acute  stage  is  at  its  height , 


URETHRITIS  431 

he  should  be  induced,  when  possible,  to  remain  in  bed,  and  a 
diet  consisting  largely  of  milk  should  be  prescribed.  He  should 
be  instructed  as  to  the  great  necessity  for  observing  cleanliness, 
and  should  be  informed  of  the  serious  danger  to  vision  that  fol- 
lows infection  of  the  eyes  with  the  discharge.  The  necessity  for 
observing  personal  cleanliness,  particularly  in  respect  to  the 
parts  that  are  concerned  in  the  trouble,  should  be  pointed  out  to 
the  patient.  This  is  best  accomplished  by  means  of  bits  of  cotton, 
or,  better  still,  pieces  of  gauze,  through  which  a  hole  has  been 
cut  for  the  insertion  of  the  glans,  and  the  foreskin  being  pulled 
down  over  it,  a  new  piece  being  appHed  after  every  urination. 
Coitus  should  be  interdicted,  and  he  should  be  warned  against 
the  excessive  use  of  tobacco.  All  alcoholic,  malt  liquors,  and 
wine  should  be  forbidden.  Strawberries  and  particularly  aspa- 
ragus should  be  avoided.  If  the  patient  cannot  be  prevented 
from  moving  about,  a  diet  as  hght  as  is  consistent  with  his  condi- 
tion and  occupation  should  be  recommended.  A  suspensory 
bandage  should  be  worn.  If  possible,  the  patient's  blood  should 
be  examined,  for  the  presence  or  absence  of  various  forms  of 
anemia  or  of  the  malarial  plasmodia.  The  nature  of  the  disease 
and  the  pathologic  condition  that  exists  should  be  carefully  ex- 
plained to  the  patient,  even  at  the  expenditure  of  considerable 
time  on  the  part  of  the  surgeon.  At  times  a  simple  pencil  sketch 
of  the  anatomy  of  the  neck  of  the  bladder  will  help  to  make  mat- 
ters clear  to  the  patient.  The  writers  have  almost  invariably 
found  that  when  the  patient's  condition  is  fully  and  patiently 
described  to  him,  he  becomes  more  submissive  and  more  amenable 
to  treatment.  Once  persuaded  that  it  is  the  desire  of  the  surgeon, ' 
after  the  acute  symptoms  have  subsided,  to  restore  the  urethral 
canal  to  complete  health,  patients  are,  as  a  rule,  willing  to  forego 
any  desire  they  may  previously  have  had  for  quick  and  powerful 
local  treatment.  It  has  been  the  writers'  experience  that  if  such 
explanations  are  made,  the  fear  entertained  by  many  practitioners 
that  unless  they  do  not  immediately  adopt  local  measures  their 
patients  will  leave  them,  is  groundless.  As  a  general  rule,  the 
small  minority  who  do  seek  the  advice  of  another  practitioner 
are  very  likely  to  return  later  on  with  one  of  the  complications  of 
urethritis,  which  renders  them  much  more  ready  to  resume  treat- 
ment. 


432  DISEASES    OF   THE    MALE    URETHRA 

For  the  relief  of  the  painful  micturition  the  following  well- 
known  prescription  will  be  found  beneficial : 

I^.     Tinct.  hyoscyami oss. 

Potassi  bicarb :  .  .  .  5 j- 

Aquae  ad  oviij. 

Sig. — Tablespoonful  in  water  three  or  four  times  daily. 

For  the  relief  of  chordee  or  painful  erections  camphor  or  the 
various  preparations  of  the  bromids  may  be  prescribed.  Cloths 
wrung  out  of  cold  water  may  also  be  applied  with  benefit.  Cold 
sitz-baths  have  been  advocated,  but  great  caution  should  be  exer- 
cised in  their  use,  particularly  by  those  who  are  feeble  or  infirm, 
for  they  are  not  infrequently  followed  by  attacks  of  neuralgia. 

Casper  advocates  the  use  of  fluidextract  of  pichi,  and  prescribes 
it  mixed  with  equal  parts  of  balsam  of  copaiba  and  oil  of  sandal- 
wood, flavored  with  oil  of  peppermint.  This  mixture  is  given  in 
doses  of  20  drops  three  times  a  day.  He  believes  that  pichi  is 
useful  for  the  relief  of  tenesmus.  While  this  may  be  so,  in  a  series 
of  experiments  carried  on  some  years  ago  for  the  purpose  of  ob- 
ser\'ing  the  effects  of  pichi  in  diminishing  the  discharge,  the  writers 
found  no  particular  effect  follow  its  use.  Casper  also  recommends 
that  tea  be  taken  frequently  during  the  day,  presumably  for  the 
astringent  effect  of  the  tannin. 

In  the  declining  stages  of  acute  anterior  urethritis  good  results 
follow  the  internal  administration  of  dram  doses  of  fluidextract  of 
hydrastis  (golden-seal).  Benefit  may  also  be  obtained  from  the 
following  capsule : 

Urotropin gr.  ij. 

Oil  of  sandalwood, 

Oleoresin  of  cubebs, 

Copaiba, 

Oil  of  nutmeg,   of  each,  ir^iij. 

One  of  these  capsules  should  be  given  three  times  a  day.  Gonosan 
capsules,  which  have  been  advocated  in  this  disease,  consist  of 
kava-kava  and  oil  of  sandalwood,  of  each,  3  decigrams;  two  of 
these  capsules  are  to  be  taken  three  times  a  day.  A  tea  made  of 
uva  ursi  is  useful  for  relieving  the  irritation  at  the  neck  of  the 
bladder.  Triticum  repens  may  also  be  of  service.  The  fluid- 
extracts  of  saw  palmetto  and  of  buchu,  of  each  a  half  teaspoonful 
two  or  three  times  a  day,  may  be  of  benefit.     When  possible, 


URETHRITIS  433 

patients  should  be  seen  at  least  once  weekly,  and  oftener  if  the 
indications  of  the  case  demand  it.  If  no  local  treatment  has  been 
given,  at  the  end  of  about  from  four  to  six  weeks  the  discharge 
begins  to  decrease  in  volume  or  lose  its  yellow  tinge,  or  both,  the 
process  tending  to  become  subacute  or  chronic.  If  the  surgeon 
was  not  decided  as  to  the  best  time  to  begin  earlier  local  treatment, 
it  may  now,  if  deemed  advisable,  be  instituted  in  a  tentative  man- 
ner, or  the  patient  may  be  kept  under  close  observation,  and  if  he 
does  well,  the  discharge  gradually  subsiding  and  finally  ceasing 
altogether,  the  urine  becoming  clear,  and  if  there  are  no  other 
indications  pointing  toward  any  continuation  of  the  disease,  the 
patient  may  be  discharged  without  receiving  local  treatment. 
It  is  well,  however,  to  inform  him  that  his  condition  was  a  serious 
one,  the  results  of  which  may  become  manifest  in  after-life,  and 
he  should,  therefore,  be  advised  to  visit  the  physician  occasion- 
ally so  that  any  after-effects  may  be  detected. 

In  acute  anterior  urethritis  in  those  cases  in  which  most  of  the 
effects  of  the  disease  are  evident  in  the  anterior  urethra,  some 
advocate  the  passage  of  a  sound  into  this  portion  of  the  urethra, 
the  discharge  diminishing  very  considerably  at  the  end  of  about 
the  fifth  week.  This  may  be  repeated  at  intervals  of  from  once  a 
week  to  once  in  five  days,  the  amount  of  secretion  being  the  guide 
as  to  the  frequency  with  which  the  instrument  should  be  passed. 
Instead  of  a  sound,  a  Kollmann  anterior  dilator  may  be  used. 
This  procedure  is  to  be  followed  in  three  days  by  irrigation  with 
silver  nitrate,  i  :  10,000,  or  ichthargin,  i  :  4000.  Patients  may  at 
the  same  time  use  an  injection  of  zinc  and  resorcin. 

Early  Local  Treatment  of  Acute  Anterior  Urethritis. — As  has 
previously  been  stated,  the  writers  deem  it  advisable,  certainly 
in  the  majority  of  cases,  to  postpone  the  local  treatment  of 
the  urethra  by  means  of  irrigations  or  injections  until  the  dis- 
charge begins  to  assume  a  mucorpurulent  character,  relying  for 
the  time  entirely  upon  proper  hygiene,  the  alkalis,  balsams,  or 
herb  teas,  as  previously  mentioned.  For  those  who  desire,  how- 
ever, to  begin  local  treatment  earlier,  the  following  methods  are 
suggested. 

One  or  two  grains  of  albargin  to  5  ounces  of  water  may  be  used 
as  an  injection  by  the  patient  four  times  a  day;  it  is  to  be  retained 
28 


434  DISEASES   OF   THE    MALE    URETHRA 

for  five  minutes.  Protargol  one  per  cent,  may  be  used  in  the 
same  manner.  If,  in  the  course  of  about  three  weeks,  the  micro- 
scope demonstrates  the  presence  of  epithelium  but  the  absence  of 
gonococci,  a  dififerent  injection  should  be  prescribed.  The  micro- 
scopic findings  at  this  time  should  determine  the  changes  to  be 
made  in  the  injection.  If  gonococci  disappear,  an  injection,  as 
mentioned  above,  may  be  used  twice  a  day,  alternating  with  the 
following:  zinc  sulphate  one  gram,  resorcin  two  grams,  water 
150  grams.  The  patient  should  then  receive  an  injection  of  this 
hquid  twice  a  day,  and  the  albargin  injections  should  be  hmited 
to  two  a  day.  Gradually  the  albargin  is  dispensed  with  and  only 
the  zinc  and  resorcin  mixture  is  used.  After  the  discharge  has 
ceased  and  threads  from  the  anterior  urethra  alone  remain,  the 
patient  may  use  silver  nitrate  injections,  i  :  10,000,  or  injections 
of  ichthargin,  i  :  5000. 

It  should  be  remembered  that  in  the  ascending  stage  astringent 
injections  will  only  tend  to  further  seal  up  the  gonococci  which 
have  already  deeply  invaded  the  tissues.  The  theory  is  that 
through  the  use  of  non-astringent  germicidals,  such  as  the  various 
albuminate  of  silver  salts, — albargin,  protargol,  or  argyrol, — if  not 
used  in  too  irritating  a  form,  the  gonococcus  is  destroyed.  In 
properly  selected  cases,  under  such  treatment  as  outlined  above, 
at  the  end  of  three  weeks,  the  gonococci  should  have  disappeared, 
or  to  have  commenced  to  disappear  from  the  secretion.  Then 
the  astringent  substances  mentioned  should  gradually  come  to 
be  used  until  the  discharge  has  almost  entirely  ceased.  The 
gonococci  having  disappeared  from  the  discharge,  the  various 
astringents  having  then  been  used  and  the  discharge  still  persist- 
ing, the  injections  should  be  changed,  and  one  of  oxycyanid  of 
mercury  i  :  4000  substituted.  Then  if  the  discharge  still  persists 
to  any  considerable  extent,  the  patient  is  probably  suffering  from 
overtreatment  and  all  local  measures  should  be  stopped,  while 
the  patient  is  still  kept  under  observation,  or  posterior  urethritis 
may  be  present  to  such  an  extent  as  to  prevent  the  cure  of  the 
anterior  urethritis.  A  certain  amount  of  posterior  urethritis 
is  not  considered  by  the  originators  of  the  above  form  of  treat- 
ment to  counterindicate  it  as  a  method  for  the  treatment  of  acute 
anterior  urethritis.     They  do   not  refrain  from  instituting  this 


URETHRITIS  435 

form  of  treatment  if  the  various  glass  tests  show  the  posterior 
urethra  to  be  only  slightly  involved,  if  no  other  clinical  evidence 
of  the  involvement  of  the  posterior  urethra  exists,  such  as  fever, 
pain  in  the  perineum,  blood  in  the  urine,  or  excessive  tenesmus 
is  present.  They  claim  that  through  this  method  they  diminish 
to  a  considerable  extent  the  proportion  of  cases  which  become 
attacked  by  severe  posterior  urethritis.  In  carrying  out  this 
early  local  treatment  the  prostate  should  be  frequently  examined, 
and  if  it  becomes  swollen  or  tender,  all  local  treatment  should  be 
stopped.  The  microscope  should  be  regularly  brought  into  use 
for  the  purpose  of  examining  the  secretions,  and  the  injections 
should  be  modified  according  to  the  findings  in  the  manner  sug- 
gested above.  The  above  method  has  been  presented,  in  an  ampli- 
fied form,  in  a  recent  edition  of  a  work  by  our  friend,  Dr.  Henry 
H.  Morton.^ 

Treatment  of  Chronic  Anterior  Urethritis 
Chronic  anterior  urethritis  only  may  be  said  to  be  present  when 
the  diagnostic  methods  described  show  that  the  posterior  urethra 
is  in  a  healthy  condition,  but  a  slight  amount  of  purulent  discharge, 
generally  of  the  morning-drop  variety,  persists  at  the  meatus  or 
there  is  an  abundance  of  threads  or  slightly  purulent  urine. 

Treatment  consists  of  injecting,  as  far  as  the  bulbomembranous 
junction,  a  weak  solution  of  silver  nitrate,  i  :  10,000,  or  the  Ultz- 
mann  injection,  of  phenol,  alum,  and  zinc  sulphate.  If  the  con- 
dition still  persists,  an  endoscopic  examination  should  be  made, 
for  the  chronic  inflammatory  state  is,  as  a  rule,  due  to  the  presence 
of  some  granulomatous  infiltration  about  one  or  several  of  the 
urethral  glands  or  to  commencing  stricture.  If  conditions  per- 
mit, the  inflamed  area  should  be  painted  through  the  endo- 
scope with  silver  nitrate  solution  or  wdth  some  other  suitable 
astringent;  or  the  treatment  may  consist  of  destruction  of  the 
diseased  glands  by  electricity,  or  of  dilatation  of  the  anterior 
urethra.  These  conditions  are  almost  invariably  associated  with 
more  or  less  chronic  posterior  urethritis,  the  proper  treatment  of 
which  will,  at  the  same  time,  tend  to  heal  the  inflamed  area  in  the 
anterior  urethra. 

^  "  Genito-Urinary  Diseases  and  Syphilis,"  1906. 


436 


DISEASES    OF   THE    MALE    URETHRA 


There  seems  to  be  marked  agreement  among  those  who  have 
observed  the  effect  of  the  silver  salts  that  they  are  most  useful  in 
hastening  eUmination  when  gonococci  are  present  if  applied  in 
dilute  form;  and  that  for  a  purulent  discharge  when  gonococci 
are  absent,  or  present  only  in  small  numbers,  solutions  of  potas- 
sium permanganate,  of  resorcin,  or  of  zinc  sulphate  are  of  benefit; 

for  cleaning  and  disinfecting 
purposes,  salt  and  water,  boric 
acid,  and  solutions  of  the  mer- 
cury oxycyanid,  i  :  4000,  are 
efficacious.  The  writers  firmly 
believe  in  the  efficacy  of  the 
old-time  injections  of  phenol, 
zinc  sulphate,  and  alum,  of 
each,  I  :  1000  to  i  :  500,  as  the 
exigencies  of  the  case  may  de- 
mand, particularly  when  doubt 
exists  as  to  whether  the  proper 
time  for  instituting  local  treat- 
ment has  arrived.  The  local 
treatment  just  outHned  for 
chronic  anterior  urethritis,  if 
injections  or  irrigations  are 
used,  may  be  carried  out  once 
daily  or  oftener  at  the  sur- 
geon's office,  using  an  irrigator, 
if  desired,  that  does  not  pene- 
trate far  beyond  the  meatus; 
of  these  there  are  many  forms 
on  the  market.  The  patient 
may  also  use  a  hand  injection, 
if  this  is  deemed  advisable. 

It  is  a  common  practice  in 
making  irrigations  of  the  ante- 
rior urethra  to  increase  the  force  with  which  the  fluid  is  thrown 
into  the  urethra  by  elevating  the  reservoir,  in  order  to  overcome 
the  resistance  of  the  constrictor  urethrge  muscle  and  thus  allow 
the  fluid  to  enter  the  bladder     The    writers  are  opposed  to  this 


Fig.  172. — F.  C.  Valentine's  irrigating  outfit. 


URETHRITIS  437 

method  of  bladder  washing,  for  they  beHeve  that  the  danger  of 
infecting  the  prostate  or  of  increasing  the  virulence  of  any  infec- 
tion that  may  exist  is  thus  enhanced.  They  recommend,  when 
it  is  desired  to  wash  the  bladder,  that  this  be  done  through  a 
small,  flexible  tipped,  bulb-pointed,  French  silk  catheter,  or 
through  the  small-sized,  soft-rubber,  velvet-e^^ed  catheter,  to  the 
end  of  which  a  hand  syringe  or  an  irrigator  may  be  attached,  as 
the  surgeon  sees  fit. 

We  are  equally  opposed  to  the  routine  method  of  forcing  fluids 
into  the  bladder  beyond  the  compressor  urethrse  muscle  by  one 
of  the  glass  hand-syringes  to  which  is  attached  a  rubber  tip  for 
the  purpose  of  thoroughly  occluding  the  meatus.  It  is  com- 
paratively easy,  by  the  use  of  one  of  these  hand-syringes,  such  as 
the  Janet,  to  force  fluid  back  of  the  compressor  urethrse  muscle, 
and  it  is  a  procedure  frequently  carried  out  as  a  routine  method 
by  which  irrigations  are  made  along  the  course  of  the  posterior 
urethra,  especially  in  some  of  the  dispensaries.  When  such 
procedure  is  carried  out,  if  the  irrigating  apparatus  is  used, 
it  should  not  have  an  elevation  above  five  feet  above  the 
urethra.  If  the  hand-syringe  with  a  rubber  tip  is  used,  as  much 
gentleness  as  possible  should  be  employed  in  making  enough 
pressure  to  force  the  fluid  used  into  the  bladder.  From  clinical 
observ^ation  of  cases  of  urethritis,  which  have  been  treated  by 
others,  and  have  afterward  come  under  our  care,  we  believe  the 
tendency  of  irrigations  which  overcome  the  contractile  power  of 
the  compressor  urethrae  muscle  by  pressure  is  to  cause  more  of 
an  infiltration  of  the  prostate  than  would  otherwise  exist.  Under 
our  observ^ation  such  prostates,  through  a  rectal  examination, 
appear  to  be  more  swollen  than  in  those  cases  of  posterior  urethritis 
in  which  irrigations  have  been  made  through  a  small  olive-pointed 
catheter,  as  advised  by  us.  Herasco,  of  Bucharest,  in  a  recent 
communication  to  the  Association  Fran9aise  Urology,^  in  dis- 
cussing abscess  of  the  prostate,  states  that  he  has  operated  forty 
times  on  abscess  of  the  prostate,  and  that  in  most  of  his  cases  the 
abscess  was  caused  by  lavage  of  the  vesical  urethra  without  the 
use  of  the  catheter.  On  the  other  hand,  it  is  hardly  necessary 
to  state,  when  irrigating  the  deep  urethra  through  a  catheter,  in 
^  "  Ann.  de  Mai.  Genito-urinaire,"  1907. 


438  DISEASES    OF   THE    MALE    URETHRA 

addition  to  the  necessary  precautions  as  regards  asepsis,  great 
gentleness  must  be  exercised ;  if  any  violence  is  used,  it  too  will 
be  liable  to  cause  infection,  and  abscess  of  the  prostate  may 
ensue. 

Treatment  of  Acute  Posterior  Urethritis 
The  pathologic  changes  that  take  place  in  acute  posterior 
urethritis  have  been  considered.  As  the  result  of  the  exam- 
ination when  the  clinical  symptoms  show  that  the  posterior 
urethra  becomes  acutely  involved,  all  local  treatment,  if  it  has 
previously  been  administered,  should  cease.  The  patient  should 
be  put  to  bed,  and  proper  hygienic  measures  instituted.  The 
writers  have  previously  expressed  the  belief  that  almost  all  cases 
of  urethritis  involve  the  posterior  urethra;  for  this  reason  they 
advocate  that  all  cases  be  treated  from  the  beginning  as  if  pos- 
terior urethritis  were  already  established.  In  severe  cases  of 
posterior  urethritis  quinin  in  small  doses  is  useful,  and  for  the 
relief  of  urgent  symptoms  salol,  sweet  spirits  of  niter,  infusions  of 
uva  ursi  or  triticum  repens,  or  hyoscyamus  and  opium  to  relieve 
pain.  The  use  of  some  of  the  infusions  the  formulas  for  which 
will  be  found  in  the  article  on  the  treatment  of  cystitis  is  recom. 
mended.  Alkahs,  if  there  are  indications  for  their  use,  and  hot 
sitz-baths  make  up,  with  the  above,  the  treatment. 

Treatment  of  Chronic  Posterior  Urethritis 
This  ordinarily  is  best  treated  by  irrigations  of  silver  nitrate, 
I  to  10,000,. or  irrigations  of  the  Ultzmann  solution  of  phenol  boric 
acid  and  zinc  sulphate  two  or  more  times  weekly,  or  by  dilation 
with  a  Kollmann  dilator  for  the  deep  urethra  or  by  a  combination 
of  the  above  methods. 

In  cases  of  chronic  posterior  urethritis  many  practitioners 
believe  in  the  efHcacy  of  instillations,  that  is,  the  application  of  a 
few  drops  of  such  a  solution  as  silver  nitrate — 2  to  10  grains  to 
the  ounce — by  means  of  a  soft  catheter  or  through  syringes,  such 
as  the  Ultzmann,  designed  for  the  purpose.  Instillations  are  not 
as  efficacious  as  irrigations  for  inflammations  of  the  posterior 
urethra  that  are  at  all  diffuse  in  character;  in  those  that  are  local- 
ized they  may  be  of  benefit.  Instillations  are  useful,  however,  and 
the  employment  of  them  is  sometimes  attended  with  remarkably 
good  results,  so  far  as  improvement  in  sensation  of  those  who 


URETHRITIS  439 

suffer  from  neurasthenia  accompanied  by  slight  inflammatory- 
lesions  in  the  posterior  urethra  is  concerned.  Instillations  are  also 
of  value  as  an  adjunct  to  other  measures  employed  in  the  treat- 
ment of  lost  or  enfeebled  sexual  power  as  a  result  of  this  condition. 
Ointments  have  been  recommended  by  many  writers  for  the 
treatment  of  chronic  posterior  urethritis,  and  exhaustive  refer- 
ence  to  them  may  be  found  in  text-books  on  the  subject.  The 
writers'  experience  with  them  has  been  limited,  the  methods  just 
mentioned  having  been  found  adequate  and  preferable.  When 
threads  alone  are  present,  zinc  sulphate  ointment  may  be  of  use. 
A  lo  per  cent,  aristol  ointment  is  serviceable  in  hyperesthesia  of 


Fig.  173- — Hutchinson's  catheter  for  applying  ointments  to  the  urethra. 

the  deep  urethra.     Other  ointments   useful  in  the  treatment  of 
chronic  posterior  urethritis  are : 

Argent,  nitrat 15    grains 

Olive  oil 1^  drams 

Lanolin 3    ounces 

or: 

Potassium  iodid IJ  drams 

lodin,  pure 15    grains 

Lanolin 3     ounces 

Olive  oil 1  ^  drams. 

The  application  should  be  made  by  means  of  a  steel  sound  de- 
vised for  the  purpose,  having  grooves  on  the  outside  to  hold  the 
ointment.  Dr.  Young,  of  Baltimore,  has  just  invented  an  inge- 
nious applicator.  The  Hutchinson  syringe  may  be  used  if  a 
Young's  applicator  or  the  grooved  sound  described  is  not  available. 
This  treatment  may  find  more  favor  in  future  when  it  has  been 
decided  which  is  the  best  ointment  base  to  use,  and  when  the 
appHcator  best  suited  for  the  purpose  has  been  made. 

Various  insufflators  have  been  devised  for  the  purpose  of  intro- 
ducing powders  into  the  urethral  canal;  however,  they  have  been 
almost  entirely  discarded.      Bismuth  was  the  base  of   most  of 


440  DISEASES    OF   THE    MALE    URETHRA 

the  powders  intended  for  this  purpose,  an  antiseptic,  such  as 
phenol,  often  being  added.  Medicated  bougies  that  melt  at  the 
body  temperature  have  been  widely  vaunted  as  a  remedy  in  this 
disease.  In  these  cacao-butter  generally  forms  the  base,  some 
antiseptic  substance,  such  as  phenol  or  iodoform,  or  an  astringent, 
such  as  zinc  sulphate,  alum,  or  copper,  generally  being  added. 
These  do  not,  apparently,  fulfil  the  indications  so  well  as  the 
other  methods  described. 

In  relapsing  cases  of  chronic  general  urethritis  hard  infiltration 
is  Hkely  to  be  present,  particularly  when  there  is  a  history  of 
previous  infections.  In  these  cases  it  may  be  found  that  quite  a 
tight  stricture  exists  in  the  urethra  at  the  bulbomembranous 
junction.  Dilation  of  the  stricture  at  proper  intervals  rapidly 
cures  the  discharge;  irrigations  temporarily  relieve  it,  but  it  is 
likely  to  return.  The  recurrent  form  of  this  disease  occurs  in 
patients  who  have  had  repeated  attacks  of  gonorrhea  extending 
over  a  series  of  several  years. 

Occasionally  the  discharge  persists  in  the  form  of  a  drop  or 
two,  and  does  not  respond  to  treatment.  An  examination  of  the 
anterior  urethra  by  means  of  the  endoscope  will  show  that  glan- 
dular infection  has  taken  place  and  that  glandular  urethritis  is 
present.  In  such  cases  the  glands  may  be  destroyed  by  electro- 
lysis, instruments  being  devised  for  that  purpose. 

A  condition  that  is  quite  frequently  seen  is  that  of  peri-ure- 
thral  urethritis,  in  which  the  glands  are  infected  just  inside  the 
meatus.  Such  glands  may  be  divided  by  a  small  knife  or  treated 
by  electrolysis. 

RtsuM^  OF  THE  Treatment  of  Urethritis 
The  writers  recommend  the  occasional  adoption  of  abortive 
measures.  They  regard  all  cases  of  urethritis  as  involving  the 
posterior  as  well  as  the  anterior  urethra,  and  treat  them  accord- 
ingly, i.  e.,  they  advise  that  no  intra-urethral  local  measures  be 
adopted  until  after  the  acute  symptoms  have  subsided  and  the 
discharge  has  become  mucopurulent,  such  measures  being  then 
adopted  as  are  indicated  for  posterior  as  well  as  anterior  urethritis, 
and  that  the  posterior  as  well  as  the  anterior  urethra  be  treated 
locally,  when  any  local  treatment  is  required,  generally  by  irriga- 
tion of  very  weak  solutions  of  silver  nitrate  or  after  some  tenta- 


COMPLICATIONS  44 1 

tive  irrigations  of  the  Ultzmann  solution  have  been  used  or  by 
dilation. 

Relapsing  cases  are  generally  due  either  to  the  too  early  insti- 
tution of  local  treatment  or  to  the  presence  of  stricture.  The 
treatment  for  this,  together  with  the  treatment  of  prostatitis, 
which  in  so  large  a  proportion  of  cases  accompanies  chronic  ure- 
thritis, will  be  dealt  with  in  a  later  portion  of  this  work. 

COMPLICATIONS 

The  complications  of  gonorrheal  urethritis  are  very  numerous, 
but  no  attempt  will  be  made  to  discuss  any  save  the  more  impor- 
tant and  frequent  of  these  complicating  conditions.  In  order 
to  obtain  a  clearer  view  of  the  complications  resulting  from  gon- 
orrhea, it  may  be  well  to  review  briefly,  in  the  light  of  our  present 
knowledge  of  pathology,  the  relations  that  exist  between  the  reac- 
tion of  the  tissues  and  the  gonococcus  when  the  body  is  invaded. 

An  acute  gonorrhea  follows  the  same  course  pursued  by  other 
infectious  conditions  in  other  portions  of  the  body,  modified  some- 
what by  the  shape  and  the  function  of  the  part  attacked.  As 
was  previously  shown,  all  the  symptoms  of  an  acute  exudative 
inflammation  appear.  The  exudation  of  pus,  which  is  so  terri- 
fying to  the  patient,  is  not  a  disease  in  itself,  but  a  symptom 
of  the  battle  that  is  being  fought  between  the  infecting  micro- 
organism and  the  forces  of  the  body — the  effort  of  nature  to 
conquer  the  infecting  hosts.  The  fluid  of  pus  is  made  up  of  serum 
from  the  blood,  which  in  itself  is  a  bactericide,  and  washes  away 
with  it  organisms  that  have  attacked  the  body,  as  well  as  the  dead 
tissues  resulting  from  the  conflict  that  is  going  on.  Swelling  of 
the  membranes  is  due  to  the  surrounding  protective  walls  of 
phagocytes  or  similar  elements  thrown  out  by  nature  to  prevent 
the  further  invasion  of  the  body,  for  nature  always  makes  an 
effort  to  protect  the  whole  as  much  as  possible.  The  body  having 
thus  been  protected  at  the  expense  of  the  urethra,  after  the  acute 
exudative  inflammation  has  passed  off,  excoriations,  granulations, 
and  beginning  formation  of  cicatricial  tissue  occur.  The  system 
has  to  a  considerable  extent  been  saved,  but  at  the  expense  of 
the  part;  hence  as  the  result,  generally,  of  constitutional  condi- 
tions or  of  unwise  treatment  complications  of  urethritis  often 
occur.     Among  these  are  phimosis,  paraphimosis,  balanitis,  lymph- 


442  DISEASES   OE   THE   MALE    URETHRA 

angitis,  invasion  of  the  parietal  glands  with  resulting  parietal 
abscesses,  and  invasion  of  the  follicular  glands  of  the  urethra 
with  resulting  follicular  abscesses.  The  prostate  and  the  seminal 
vesicles  often  become  involved,  cystitis  may  ensue,  and  inva- 
sion of  the  kidney  and  pyelonephritis  may  result.  The  nervous 
system  is  occasionally  attacked,  and  myelitis  and  meningitis  of 
gonorrheal  origin  may  occur.  Involvement  of  the  testicles  mani- 
fests itself  by  the  onset  of  epididymitis  and  orchitis,  which  may 
lead  to  stenosis  of  the  vas  deferens,  producing  sterility.  Osteomye- 
litis, phlebitis,  pulmonary  infarct,  pleuritis,  and  endocarditis  may 
occur. 

Gonorrhea  of  the  mouth  and  of  the  rectum  is  extremely  rare, 
but  cases  are  occasionally  reported,  and,  according  to  Caspar, 
gonorrheal  stomatitis  of  the  newborn  is  found  now  and  then.  Cas- 
par quotes  Jaddeson  as  saying  that  gonorrhea  of  the  rectum  has 
been  known  to  result  from  rupture  of  a  prostatic  abscess,  as  well 
as  from  direct  inoculation. 

Gonorrhea  of  the  eye  and  gonorrheal  rheumatism  are  such 
frequent  complications  that  they  merit  detailed  description  here. 
For  the  following  article  on  "Gonorrhea  of  the  Eye"  we  are  in- 
debted to  Dr.  Richard  KaHsh,  of  New  York. 

Gonorrhea  of  the  Eye. — Specific  urethritis  may  cause  both 
extra-ocular  and  intra-ocular  disease,  the  most  frequent  mani- 
festation of  the  former  being  acute  blennorrhea  of  adults,  and  of 
the  latter,  iritis.  s 

Acute  blennorrhea,  called  also  purulent  or  gonorrheal  conjunc- 
tivitis or  ophthalmia,  is  due  to  contamination  from  urethral 
discharges,  usually  carried  by  the  fingers  of  the  patient ;  one  eye 
is  first  affected,  and  it  is  generally  possible  to  tell  from  this  whether 
the  sufferer  is  right  or  left  handed.  Other  means  of  infection  are 
the  hands  of  nurses  and  soiled  dressings.  In  four  cases  seen  in 
the  writer's  practice  the  source  of  infection  was  traced  to  the 
towels  used  in  the  offices  where  patients  were  employed.  From 
an  extensive  clinical  experience,  the  writers  cannot  concur  in  the 
opinion  that  the  toxins  of  the  gonococcus  circulating  in  the  sys- 
tem may  produce  gonorrheal  conjunctivitis. 

Symptoms. — In  every  case  of  this  disease  the  gonococcus  of 
Neisser  is  present.  The  symptoms  appear  very  soon  after  inocu- 
lation,— usually  within  forty-eight  hours, — and  at  first,  on  casual 


COMPLICATIONS  443 

inspection,  resemble  those  of  acute  catarrhal  conjunctivitis;  a 
closer  examination,  however,  discloses  the  fact  that  the  ocular 
conjunctiva  presents  a  more  brawny  and  turgid  aspect.  Great 
swelling  rapidly  supervenes,  with  intense  congestion  of  the  con- 
junctiva, and  a  marked  chemosis  forms  an  elevated  ring  surround- 
ing the  cornea  which  appears  as  if  sunken  to  the  bottom  of  a  pit. 
The  slight  opalescent  excretion  quickly  gives  way  to  a  very  profuse, 
greenish  yellow  discharge,  presenting  the  physical  characters  of  that 
of  gonorrhea.  Unless  modified  by  active  and  unremitting  treat- 
ment, all  these  symptoms  rapidly  become  aggravated.  Ulcers 
appear  on  the  cornea  and  may  perforate  it,  or,  as  has  occurred 
in  the  writer's  hospital  service,  the  entire  cornea  may  slough,  ex- 
trusion of  the  ocular  contents  and  collapse  of  the  globe  following. 
In  other  cases,  after  a  small  perforation  has  taken  place,  prolapse 
of  the  iris  occurs,  which  is  succeeded  by  infection  of  all  the  deeper 
structures,  setting  up  a  general  inflammation  or  panophthalmitis. 

Prognosis. — With  the  modern  treatment  of  this  disease  recovery 
may  usually  be  expected  and  the  dangerous  sequelae  of  the  past — 
leucomata,  partial  or  complete  staphyloma,  incarceration  or 
synechia  of  the  iris,  and  panophthalmitis — do  not  often  follow, 
provided  the  patient  is  seen  early  in  the  attack  and  before  there 
has  been  any  interference  with  the  nutrition  of  the  cornea. 

Treatment. — One  eye  being  usually  first  affected,  the  other 
should  be  protected  from  infection  by  covering  it  with  a  Buller's 
shield;  this  is  made  of  a  watch-crystal  of  large  size  (the  writer 
uses  a  lens  from  the  so-called  driving  glasses),  fitted  in  an  oval 
piece  of  rubber  adhesive  plaster.  This  is  carefully  applied  to 
brow,  nose,  and  cheek,'  but  not  to  the  temple,  for  if  hermetically 
sealed,  the  insensible  perspiration  within  the  shield,  condensing 
on  the  inside  of  the  lens,  would  smear  it  and  thus  prevent  the 
early  recognition  of  infection  of  this  eye,  if  this  unfortunately 
occurs.  The  rubber  plaster  easily  becomes  loosened;  the  edge 
and  the  contiguous  skin  should,  therefore,  be  painted  with  flexible 
collodion  into  which  a  few  shreds  of  absorbent  cotton  should  be 
incorporated  before  the  collodion  hardens ;  the  union  of  protector 
and  skin  will  then  be  complete. 

Unremitting  care  is  the  key  to  the  successful  treatment  of  this 
disease.  Ice-cold  compresses  must  be  applied  continuously  as 
long  as  the  cornea  remains  unclouded.     They  are  best  used  in  the 


444  DISEASES    Olf   THE    MALE    URETHRA 

form  of  two-inch  squares  of  patent  lint  which  should  be  placed  on 
a  block  of  ice.  These  compresses  must  be  changed  often  enough 
to  keep  the  lids  chilled — about  from  every  fifteen  to  thirty  seconds 
at  first;  later  at  longer  intervals.  Before  applying  them  to  the 
eyelids  the  integument  should  be  anointed  with  an  ointment 
consisting  of  equal  parts  of  cosmoHn  and  simple  cerate.  Vaselin 
is  too  quickly  washed  away  to  prevent  the  dermatitis  caused' by 
the  cold  application.  Every  three  hours  a  small  lump  of  white 
vaselin  should  be  placed  under  the  lids  by  means  of  a  probe. 
The  discharge  must  be  removed  as  rapidly  as  it  forms,  for  the 
integrity  of  the  globe  is  threatened  not  only  by  the  swelling  of 
the  lids  and  ocular  conjunctiva,  causing  nutritional  interference, 
but  also  by  the  acridity  of  the  secretion.  Success  is  impossible 
unless  absolute  cleanliness  is  maintained;  therefore  the  advice 
to  clean  the  eyes  every  twenty  minutes  cannot  be  too  severely 
censured.  The  discharge  must  be  wiped  away  as  soon  as  it 
forms — at  first  every  time  a  cold  pad  is  applied.  Irrigations  of  a 
warm  saturated  solution  of  boric  acid  should  be  employed  at  least 
every  fifteen  minutes.  Solutions  of  mercuric  bichlorid,  biniodid, 
or  cyanid  cannot  be  used  in  germicidal  strength  and  are,  even  in 
these  weak  solutions,  too  irritating.  The  irrigator  should  not 
be  placed  at  a  height  of  more  than  i8  inches  above  the  head  of 
the  patient,  and  the  solution  should  flow  over,  and  not  strike, 
the  eyeball.  As  soon  as  the  cornea  assumes  a  steamy  appear- 
ance the  use  of  the  cold  pad  must  be  discontinued  and  heat,  as 
strong  as  the  eye  can  bear,  must  be  substituted.  If  hot  com- 
presses are  employed,  the  water  should  be  heated  at  the  bedside. 
The  best  method  of  applying  heat  is  to  fill  a  glass  to  the  brim 
with  hot  water  and  let  the  patient  hold  this  to  the  eyelids,  open- 
ing and  closing  the  eye  under  the  water.  Irrigation  should  be 
practised  as  often  as  the  discharge  accumulates,  even  if  required 
at  five-minute  intervals.  Alum  should  never  be  appHed,  as  it  dis. 
solves  the  cement  holding  the  corneal  plates,  and  thus  favors  the 
entrance  of  micro-organisms,  to  the  subsequent  danger  of  the  eye- 
ball. For  similar  reasons  cocain  should  not  be  used,  except  early 
in  the  attack.  To  arrest  the  discharge  and  to  destroy  the  gonococ- 
cus  protargol  or  argyrol  should  be  thoroughly  applied  to  the  con- 
junctiva in  from  lo  to  25  per  cent,  solutions.  These  applications 
should  be  made  from  every  three  to  six  hours,  depending  upon 


COMPLICATIONS  445 

the  quantity  of  the  discharge  and  the  rapidity  of  its  production. 
These  remedies  are  much  superior  to  the  argentic  nitrate,  since 
they  may  be  used  from  the  very  inception  of  the  trouble,  whereas 
the  nitrate  must  never  be  used  until  the  stage  of  secretion  is  fully 
established;  the  latter,  furthermore,  does  not  penetrate  the  in- 
fected tissues  as  do  both  protargol  and  arg\^rol. 

The  writer  does  not  favor  scarification  to  relieve  the  turgid 
conjunctiva,  as  it  is  likely  to  permit  infection  of  the  deeper  seated 
structures.  Marked  benefit  may  be  obtained  by  the  application 
of  three  or  four  leeches  to  the  temple,  the  bleeding  being  favored 
by  hot  fomentations.  Leeching  may  advantageously  be  repeated 
in  selected  cases  every  third  or  fourth  day. 

Whenever  swelling  of  the  lids  produces  injurious  pressure  on 
the  globe,  a  canthotomy  should  be  performed.  Corneal  ulceration 
when  centrally  located  calls  for  atropin;  if  situated  peripherally 
for  eserin  or  pilocarpin.  Abscission  should  never  be  performed 
for  prolapse  of  the  iris,  for  this  opens  up  a  channel  for  infection  of 
the  deep  structure  of  the  eye,  and  subsequently  panophthalmitis 
will  occur.  The  eyelids  sometimes  recover  completely,  but  in 
other  cases  there  follows  a  true  trachomatous  process,  which 
demonstrates  that  trachoma  is  a  hypertrophy  of  the  subconjunc- 
tival adenoid  tissue,  resulting  from  inflammation,  etc.,  instead  of 
being  caused  by  a  special  micro-organism.  For  this  sequel  scarifi- 
cation, followed  by  the  application  of  tannic  acid  in  glycerin  (2 
to  10  per  cent,  solution),  will  usually  effect  complete  recovery. 

Ophthalmia  Neonatorum. — Ophthalmia  of  the  new-born  is  due 
to  infection  contracted  during  the  passage  of  the  child's  head 
through  the  mother's  vagina.  Other  modes  of  infection  are  those 
mentioned  as  occasionally  operative  in  the  causation  of  gonorrheal 
conjunctivitis  in  adults.  There  are  two  types  of  this  disease — a 
mild  one,  which  yields  readily  to  the  ordinary  treatment  for  acute 
catarrhal  conjunctivitis,  and  a  virulent  one,  in  which  the  gono- 
coccus  is  always  present.  As  a  rule,  with  proper  precautions, 
this  is  a  preventable  disease ;  and  as  rehable  statistics  have  shown 
chat  from  30  to  55  per  cent,  of  all  cases  of  blindness  are  due  to 
this  condition,  neglect  to  observe  such  precautions  is  criminal. 
In  all  suspected  cases  the  Crede  preventive  method  should  be 
adopted,  i.  e.,  as  soon  as  the  child  is  born  or,  better,  as  soon  as  the 
head  emergtes  from  the  vulva,  the  face  should  be  cleaned,  the 


446  DISEASES   OF    THE    MALE    URETHRA 

eyelids  separated,  and  one  drop  of  a  2  per  cent,  solution  of  silver 
nitrate  should  be  instilled  in  each  eye.  In  extremely  rare  instances 
conjunctivitis  follows  this  treatment,  demanding  the  use  of  cold 
compresses,  cocain,  and  irrigations  with  warm  boric  acid  solution; 
as  a  rule,  how^ever,  there  is  no  reaction  to  the  silver  application. 
When  ophthalmia  neonatorum  does  occur,  the  treatment  should 
be  as  active  and  energetic  as  that  recommended  for  purulent 
ophthalmia  in  the  adult. 

Iritis. — This  is  the  most  frequently  observed  form  of  intra- 
ocular disease  due  to  systemic  involvement.  Not  infrequently 
the  attack  cannot  be  differentiated  from  rheumatic  iritis.  Usu- 
ally a  knee-joint  is  first  affected,  then  the  eye,  and  in  some  ca'ses 
these  alternate.  The  iritis  is  often  bilateral,  attacking  the  eyes 
simultaneously  or  in  succession.  The  symptoms  and  course  are 
identical  with  those  of  rheumatic  iritis,  and  as  these  attacks  occur 
so  often  in  patients  who  are  the  subjects  of  rheumatism  at  other 
times,  the  gonorrheic  implication  is,  to  say  the  least,  a  doubtful  one. 

There  is,  however,  one  form  of  iritis  that  seems  to  depend  on 
metabolism  of  the  gonococcus.  It  occurs  early  in  the  course  of 
the  gonorrhea,  none  of  the  avascular  structures  of  the  joint  being 
affected.  It  usually  attacks  but  one  eye,  although  both  may  be 
affected,  and  severe  inflammation  is  the  rule.  The  pupil  is  often 
occluded  by  a  grayish  lymph,  and  there  may  be  an  abundant 
exudation  in  the  anterior  chamber.  If  seen  early  in  the  attack,  a 
cure  is  confidently  to  be  expected.  A  striking  case  of  this  kind 
was  seen  in  the  summer  of  1905.  The  patient's  first  attack  of 
gonorrhea  was  accompanied  by  a  severe  iritis.  A  similar  condi- 
tion occurred  with  his  second  attack,  and  also  with  the  third — for 
which  the  writer  was  consulted.  Only  one  eye — the  right  one — 
was  affected.  He  had  never  had  rheumatic  attacks,  and  had 
suffered  but  these  three  attacks  of  gonorrhea,  in  each  of  which 
iritis  supervened  within  ten  days  after  the  urethral  discharge 
had  been  established. 

Among  other  intra-ocular  diseases  attributed  to  the  toxins 
generated  by  the  gonococcus  are  cyclitis,  iridocyclitis,  and  chorio- 
retinitis. In  the  course  of  a  gonorrheal  attack  of  long  standing 
amblyopia  has  been  observed  to  occur.  In  these  cases  the  dis- 
tinctive symptoms  are  a  sluggish  and  slightly  dilated  pupil,  with 
hazy  vision,  scintillating  scotomata,  and  an  inability  to  read  or 


COMPLICATIONS  447 

write  for  more  than  a  few  minutes  at  a  time.  In  a  case  seen  in 
the  writer's  private  practice  there  was  Ukewise  a  restriction  of  the 
field  of  vision  for  both  eyes,  at  the  nasal  side.  When  the  gonor- 
rhea was  cured,  complete  visual  restoration  followed. 

Gonorrheal  Rheumatism. — This  term  is  most  unfortunately 
chosen,  and  is  unquestionably  responsible  in  part  for  the  misunder- 
standing so  prevalent  in  regard  to  the  disease.  It  is  to  be  classed 
in  no  way  with  any  variety  of  rheumatism  except  in  point  of 
differential  diagnosis.  It  is  due  to  a  specific  and  well-accepted 
etiologic  factor,  affecting  the  synovial  sacs,  the  tendinous  sheaths, 
and  in  rare  cases  the  investment  of  the  nerve-trunks  as  a  simple 
inflammatory  process.  It  is  an  infectious  synovitis,  and  is  due 
in  all  instances  to  infection  with  the  gonococcus,  though  in  some 
instances  the  infection  may  be  mixed.  In  a  sufficient  number  of 
cases  the  gonococcus  has  been  recovered  from  joints  involved, 
though  on  account  of  the  elusive  nature  of  this  organism  to  ordinary 
methods  of  bacterial  investigation,  it  may  not  be  always  possible 
to  demonstrate  it.  There  is  some  evidence  to  indicate  that  the 
organism  itseh  may  not  invariably  be  present  in  the  involved 
areas,  but  that  the  symptoms  are  due  to  the  production  of  some 
toxic  body,  specific  in  nature,  which  is  elaborated  by  or  in  the 
presence  of  gonococci.  This  toxic  theory  is  largely  substantiated 
by  the  fact  that  very  frequently,  when  the  original  nidus  of  infec- 
tion be  healed,  the  disease  disappears  spontaneously  without  local 
treatment  of  the  inflamed  tissues  of  the  joint  or  general  measures. 

In  the  opinion  of  the  writers,  however,  subjects  especially  sus- 
ceptible to  rheumatic  diseases  are  rather  more  liable  to  develop 
gonorrheal  synovitis  rather  than  those  not  so  inclined.  "We 
explain  this  fact  by  the  theory  of  lowered  tissue  resistance.  The 
disease  is  not  a  very  frequent  one,  fortunately,  but  occurs  in  the 
experience  of  every  general  practitioner,  internist,  surgeon,  and 
urologist  with  quite  sufficient  frequency.  A'arious  writers  esti- 
mate the  proportion  of  occurrence  at  from  2  to  lo  per  cent,  of 
the  total  number  of  cases  of  gonorrhea.  It  undoubtedly  occurs 
more  commonly  in  male  than  in  female  patients.  This  is  prob- 
ably largely  explained  by  the  fact  that  in  the  male  gonorrhea  is 
more  apt  to  be  a  persistent  disease  in  which  hidden  foci  of  possible 
infection  exist  for  a  longer  period  than  is  common  in  women,  except 
in  instances  of  uterine  or  tubal  infection. 


448  DISEASES   OF  THE    MALE    URETHRA 

Course. — Gonorrheal  synovitis  rarely  appears  during  the  acute 
stages  of  an  active  infection,  but  is  most  common  in  the  later 
stages,  and  is  seen  rarely  in  cases  which  are  free  from  complicating 
lesions,  such  as  a  serious  posterior  urethritis,  epididymitis,  or 
gonorrheal  vesiculitis.  It  may  arise,  however,  during  the  early 
acute  stages,  particularly  in  secondary  or  recurrent  cases,  or  it 
may  occur  months  after  the  original  infection  has  subsided.  In 
practically  all  the  instances  which  have  fallen  under  the  observa- 
tion of  the  writers  some  focus  of  persistent  infection  could  be 
demonstrated  after  sufficient  search.  The  most  frequent  seats 
for  such  foci  in  our  experience  have  been  the  posterior  urethra, 
and  especially  prostatic  abscess  and  vesiculitis.  In  many  cases 
the  local  symptoms  are  so  slight  as  to  fail  to  attract  the  attention 
of  either  the  patient  or  the  careless  clinician.  The  frequency 
with  which  the  disease  arises  after  forceful  instrumentation  in 
cases  of  gleet  or  posterior  urethritis  should  be  held  as  very  sig- 
nificant. 

The  onset  of  the  disease  is  rarely  acute  and  active,  but  is  more 
apt  to  be  relatively  slow  and  to  be  preceded  by  several  hours, 
days,  or  weeks  of  mild  pains  in  the  region  of  the  infected  joint. 
With  the  onset  there  is  commonly  a  moderate  rise  in  temperature, 
with  proportionate  quickening  of  the  pulse,  pains  in  the  back,  and 
the  general  symptoms  of  infection.  Occasionally  the  disease  is 
violently  inaugurated,  with  rigor,  high  temperature,  and  profuse 
sweating.  Ordinarily, but  a  single  joint  is  at  first  involved,  though 
subsequently  others  may  become  invaded.  The  joint  most  fre- 
quently attacked  is  the  knee,  the  tendons  of  the  foot,  such  as  the 
tendon  at  the  plantar  aponeurosis  or  the  calcaneus,  often  being 
likewise  affected.  It  may  attack  other  portions  of  the  feet,  may 
give  rise  to  periosteitis  of  the  calcaneus,  and  may  cause  myositis 
and  various  forms  of  synovitis.  Next  to  the  knee  and  the  foot, 
it  shows  a  predilection  for  the  elbow.  Occasionally  the  attack  ter- 
minates in  suppuration,  which  possibly  breaks  through  the  joint, 
with  the  usual  accompaniments  of  abscess  formation,  such  as 
fever  and  chills.  It  is  stated,  and  we  believe  correctly,  that  with 
the  onset  of  the  synovitis  an  increase  or  reappearance  of  the  ureth- 
ral discharge  is  likely  to  develop. 

The  involved  joint  swells,  oftentimes  to  a  considerable  degree, 
but  it  rarely  takes  on  the  deep-red  color  seen  in  the  average  case 


COMPLICATIONS  449 

of  acute  articular  rheumatism.  Movement  of  the  articulation 
is  productive  of  exquisite  pain,  but  when  the  joint  is  immobolized 
and  kept  at  absolute  rest,  the  pain  is  generally  not  so  great  as  in 
articular  rheumatism.  The  disease  may  be  accompanied  by  severe 
sweating,  but  this  is  never  so  pronounced  as  in  true  rheumatism, 
nor  is  the  sweat  of  so  striking  and  acrid  an  odor.  Prostration 
is  generally  not  marked,  except  in  those  cases  complicated  by 
bacteriemia  and  endocarditis.  Endocarditis  is  occasionally  seen 
as  an  accompanying  lesion,  but  it  never  occurs  with  the  frequency 
with  which  it  is  seen  in  rheumatism. 

Diagnosis. — The  disease  must  be  differentiated  from  acute 
articular  rheumatism,  from  simple  synovitis,  rheumatic  gout,  and 
acute  cases  of  tubercular  arthritis,  and  from  occasional  instances 
of  acute  syphilitic  synovitis.  One  of  the  most  important  steps 
in  the  diagnosis  is  the  history  of  a  relatively  recent  attack  of  gonor- 
rhea, and  in  a  large  percentage  of  cases  the  detection  of  foci  in 
which  gonococci  may  still  be  demonstrated.  The  less  prostration 
and  sweat,  the  less  tendency  to  migrate  from  joint  to  joint,  and 
the  less  frequent  occurrence  of  endocarditis  are  important  points 
in  the  differentiation  from  acute  articular  rheumatism.  Where 
endocarditis  is  present,  blood  cultures  may  show  the  presence  of 
the  gonococcus,  on  the  one  hand,  or  of  the  streptococcus  or  staphy- 
lococci, on  the  other.  Similarly,  in  cases  of  simple  arthritis,  in 
cases  of  septic  nature,  the  demonstration  of  the  nature  of  the  hemic 
infection  is  a  point  of  very  conclusive  value.  Leukoc}i:osis,  which 
is  absent  in  the  gonorrheal  condition,  is  also  a  helpful  diagnostic 
sign  in  general  septic  states. 

The  differentiation  from  rheumatic  gout  is,  in  our  opinion,  most 
difficult  in  many  instances,  and  in  some  cases  must  rest  on  the 
results  of  treatment  if  gonococci  cannot  be  found  in  any  of  the 
usual  tracts.  From  acute  tubercular  arthritis,  the  less  active 
nature  of  the  infection,  the  detection  of  tubercular  foci  elsewhere, 
or  the  presence  of  a  Calmette  or  vaccination  tubercular  reaction 
are  points  of  importance.  Within  a  few  days'  time  the  differ- 
entiation from  acute  syphilitic  synovitis  is  a  matter  of  ease,  owing 
to  the  appearance  of  other  manifestations  of  this  general  infection. 

Prognosis. — The  prognosis  as  regards  life  is  good.  Gonorrheal 
rheumatism  shows  a  tendency  to  go  on  to  recovery,  in  the  majority 
of  cases,  in  from  three  to  four  weeks,  without  receiving  any  treat- 
29 


450  DISEASES    OF   THE    MALE    URETHRA 

ment  whatever;  some  cases  have,  however,  been  known  to  per- 
sist for  months  in  previously  healthy  individuals. 

Owing,  probably,  to  continued  absorption  of  the  virus  of  gonor- 
rhea from  the  urethral  wall,  in  a  small  proportion  of  cases  a  very 
obstinate  form  of  arthritis  is  set  up — knee-  or  elbow-joints,  syno- 
vial tendon-sheaths  of  wrist  or  foot,  etc.,  may  be  affected  by  an 
inflammatory  process  secondary  to  the  gonorrhea.  This  generally 
takes  the  form  of  a  hydrops  of  synovia,  which  is  very  slow  to 
clear  up  and  appears  about  three  or  four  weeks  after  the  infec- 
tion has  taken  place.  Very  rarely  suppuration  occurs  in  all  the 
involved  joints,  with  the  attendant  dangers  of  pyemia.  The 
disease  may  in  such  cases  terminate  in  more  or  less  stiffened  joints, 
and  ankylosis  is  not  unknown. 

Treatment. — This  primarily  consists  in  the  treatment  of  any 
inflammatory  conditions  of  the  urethral  canal  that  may  exist. 
Most  commonly  a  posterior  urethritis  is  present  in  conjunction  with 
the  rheumatic  symptoms,  and  this  must  receive  the  proper  treat- 
ment, such  as  occasional  deep  irrigations  with  weak  solutions  of  sil- 
ver nitrate.  The  results  of  the  employment  of  very  heroic  measures 
in  the  treatment  of  inflammatory  conditions  of  the  urethral  canal, 
such  as  opening  the  seminal  vesicles  for  the  cure  of  gonorrheal 
rheumatism,  are  difficult  to  estimate  properly.  If  skilfully  car- 
ried out,  these  measures  may  produce  excellent  results,  and  in 
some  of  our  cases  great  benefit  has  followed.  The  method  is 
not  one,  however,  for  general  use,  and  probably  has  a  very  limited 
field  of  application.  The  fact,  however,  that  gonorrheal  syno- 
vitis shows  a  tendency  to  recover  is  one  of  the  reasons  why 
it  is  so  difficult  to  estimate  the  amount  of  benefit  actually  derived 
from  the  use  of  any  therapeutic  measure,  medical  or  surgical. 
The  affected  joints  should  be  immobilized.  Applications,  either 
of  heat  or  cold,  as  the  patient  may  find  most  soothing,  should 
be  made.  Cloths  wrung  out  of  hot  lead-and-opium  solution 
and  reapplied  as  frequently  as  they  become  cool  will  be  found 
useful  when  the  pain  is  severe.  In  a  few  cases  we  have  found 
the  application  of  ice-bags  or  cloths  soaked  with  ice  water 
to  give  great  relief.  Vasogen  iodin  may  be  well  rubbed  into 
the  affected  joints  two  or  three  times  a  day;  this  has  been 
especially  efficient  in  chronic  and  persistent  cases.  This  same 
local  treatment  will  also  be  found  beneficial  in  other  conditions, 


COMPLICATIONS  45 1 

such  as  involvement  of  the  synovial  sheaths.  An  ointment  com- 
posed of  ichthyol  and  oil  of  wintergreen  has  acted  well  in  some 
cases.  Various  other  stimulating  applications,  such  as  chloroform 
liniment  or  one  of  the  menthol  preparations,  may  be  employed. 

Internally,  the  treatment  should  be  that  of  septicemia;  tonics 
of  iron,  quinin,  and  manganese,  sulphur  compounds,  and  prepara- 
tions of  phosphorus  may  all  be  employed  advantageously.  It 
is  the  custom  to  recommend  salol,  aspirin,  and  various  other 
forms  of  the  coal-tar  products,  which  have  a  decided  analgesic 
action  and  also  serve  as  urinary  antiseptics.  We  have  found 
aspirin  the  most  efficient  of  this  class.  Urotropin  sometimes 
acts  well,  probably  for  the  same  reason.  In  some  cases  the  use 
of  powerful  hypnotics,  as  codein,  veronal,  and  morphin,  may 
become  imperative.  It  has  been  our  custom,  for  many  years 
past,  to  employ  oil  of  wintergreen,  five  to  twenty  drops,  three 
times  a  day.  In  a  good  many  cases  this  relieves  the  pain,  but  we 
do  not  feel  that  it  materially  shortens  the  course  of  the  disease. 

In  some  chronic  cases  the  alternating  hot  and  cold  spray  acts 
well,  and  in  persistent  cases  we  have  used  the  Bier  hyperemic 
treatment  with  signal  success;  in  one  instance,  however,  we 
must  note  that  the  disease  appeared  to  become  much  worse  after 
this  method.  The  use  of  dry  heat  and  the  x-ray  both  have  their 
advocates,  but  our  experience  does  not  lead  us  to  favor  either. 
Massage  and  passive  movements  are  also  to  be  used  only  with 
great  care,  and  alone  in  quiescent  cases.  The  general  tone  of  the 
body  should  be  improved,  and  for  this  purpose  glycerophosphates 
and  various  other  constructive  tonics  in  large  doses  will  be  found 
beneficial. 

In  our  experience  we  have  not  found  it  necessary  to  restrict 
the  diet,  as  in  rheumatism,  and  for  most  largely  afebrile  cases  we 
recommend  a  full  and  nourishing  though  readily  digestible  diet. 

The  serum  and  gonococcus  vaccine  treatment  of  gonorrheal 
rheumatism,  both  acute  and  chronic,  and  for  such  conditions 
as  epididymitis  has  justly  of  late  received  consideration  by  many 
observers.  From  our  own  investigations,  in  which  we  have  been 
aided  by  H.  M.  Beardall,  House-Surgeon  of  the  New  York  City 
Hospital,  we  feel  that  we  can  speak  more  positively  as  to  their 
merits  than  in  the  preceding  editions  of  this  work.  The  serum  is 
a  product  of  cultures  of  gonococci  injected  into  horses.     After 


452  DISEASES    OF    THE    MALE    URETHRA 

a  time  the  horses  are  bled,  and  the  blood  serum  (antigonococcic 
serum)  used  to  combat  infections  of  the  gonococcus. 

The  gonococcus  vaccine  is  a  suspension  of  dead  gonococci  of 
various  strains  in  saline  solution.  We  have  found  the  serum 
useful  in  the  treatment  of  acute  gonorrheal  rheumatism,  and 
in  a  lesser  degree  in  the  treatment  of  chronic  gonorrheal  joint 
conditions.  It  should  be  injected  to  the  amount  of  2  c.c.  at  a 
time,  the  injections  repeated  at  intervals  of  two  or  three  days, 
and  several  injections  used  unless  amelioration  of  the  symptoms 
have  taken  place.  It  is  advised  by  the  manufacturers  to  follow 
up  the  serum  with  injections  of  the  vaccine.  So  far  we  have  not 
been  as  successful  with  the  vaccines  as  with  the  serum.  We 
think  we  have  found  the  vaccine  of  some  benefit  in  the  treatment 
of  epididymitis.  We  have  used  the  vaccine,  commencing  with 
doses  of  10,000,000  bacteria  per  cubic  centimeter  and  working  up, 
injecting  the  vaccine  at  intervals  of  three  to  five  days.  We  have 
used  the  serum  and  vaccine  as  put  up  by  Parke,  Davis  &  Co., 
following  the  suggestions  of  Dr.  Seaborn,  the  Director  of  their 
Scientific  Department.  We  have  not  had  any  unpleasant  after- 
effects follow  the  use  of  either  the  serum  or  the  vaccine.  For  ure- 
thritis, acute  and  chronic,  the  above  preparations  are  of  no  value. 

When  complications,  such  as  ankylosis,  persistafter  recovery  from 
the  acute  condition  has  taken  place,  these  should  be  treated  accord- 
ing to  the  rules  laid  down  in  the  text-books  on  orthopedic  surgery. 

Gonorrheal  Endocarditis.^ — Gonorrheal  involvement  of  the 
endocardium  is  probably  a  much  more  frequent  disease  than  is 
generally  recognized.  Since  it  may  occur  in  mild  form  with  no 
more  septic  reaction,  in  the  way  of  fever,  chills,  or  prostration, 
than  might  be  accounted  for  by  the  urethral  condition,  it  is  highly 
probable  that  cases  have  slipped  the  notice  of  all  of  us.  The 
lesion  is,  of  course,  most  apt  to  arise  in  the  course  of  gonorrheal  bac- 
teremia or  synovitis,  but  may  be  seen  in  apparently  simple  cases. 

As  a  rule,  the  symptoms  are  quite  pronounced,  and  are  mani- 
fested by  night  temperature,  with  morning  fall,  chill  at  onset,  and 
a  typical  septic  course.  As  with  ordinary  acute  endocarditis, 
the  temperature-curve  may  strongly  suggest  malarial  infection. 
As  just  mentioned,  clinical  manifestations  may,  however,  be  slight 
and  pass  unrecognized  until  the  heart  examination  shows  the 
presence  of  an  acute  murmur.     As  a  rule,  the  mitral  segments 


COMPLICATIONS  453 

are  mostly  involved,  and  next  to  these  the  aortic  flaps.    These  are 
the  only  two  valves  which  we  personally  have  found  so  diseased. 

Diagnosis  must  rest  on  the  detection  of  the  murmur,  with  the 
usual  symptoms  of  endocarditis,  associated  with  gonorrheal  in- 
fection, but  absolute  diagnosis  is  only  possible  when  the  gonococ- 
cus  can  be  isolated  from  blood-cultures.  By  no  means  all  cases 
of  endocardial  infection  arising  in  the  course  of  gonorrhea  are  of 
this  specific  nature,  for  other  organisms  may  enter  through  the 
disease  focus.  A  case  of  gonorrheal  synovitis  recently  seen  in 
the  service  of  one  of  the  writers  showed  the  development  of  an 
acute  endocarditis,  with  classic  signs  and  symptoms.  The  case 
was  naturally  supposed  to  be  one  of  gonorrheal  endocarditis, 
but  blood-cultures  showed  the  gonococcus  absent  and  a  strepto- 
coccus present. 

In  the  few  cases  which  have  fallen  under  our  clinical  observation 
the  general  course  of  the  disease  has  been  less  violent  than  in  ordi- 
nary endocarditis.  No  detectable  infarctions  have  appeared,  and 
all  save  one  of  our  cases  recovered.  Other  observers  record  quite 
contrary  findings,  and  it  seems  probable  that  our  fortunate  results 
were  entirely  a  matter  of  chance. 

The  treatment  consists  of  the  usual  measures  employed  in  acute 
ulcerative  endocarditis,  plus  active  treatment  of  the  local  gonor- 
rhea. Rest  in  bed  and  the  ice-bag  to  the  precordium  are  the  most 
important  of  the  measures  specifically  directed  to  the  cardiac 
disease. 

Stricture  of  the  Meatus 

In  the  male  this  is  quite  common ;  less  so  in  the  female.  Gen- 
erally it  is  hereditary,  although  it  may  be  the  result  of  disease. 
The  meatus  occasionally  being  only  pin-hole  in  size,  admitting 
only  a  small  instrument,  conditions  similar  to  the  above  may 
cause  no  trouble,  except  that  if  infection  of  the  urethra  has  once 
taken  place,  the  size  of  the  meatus  may  interfere  with  drainage 
and  may  retard  recovery,  which  would  be  materially  hastened 
by  incision  of  the  opening.  It  is  frequently  necessary  to  enlarge 
the  meatus  by  incision  to  obtain  room  for  the  introduction  of 
such  an  instrument  as  a  cystoscope.  Meatotomy  is  performed  as 
follows:  Soak  a  pledget  of  cotton  wrapped  around  the  end  of  an 
applicator  or  probe  in  a  4  per  cent,  solution  of  cocain;  insert  it 
into  the  urethra  for  an  inch;    apply  over  the  frenum   another 


454  DISEASES    OF   THE   MALE    URETHRA 

pledget  of  cotton  soaked  in  cocain  and  have  the  patient  make 
pressure  over  the  two  for  ten  minutes;  then  remove  the  cotton 
from  the  frenum  and  the  cotton  plug  from  the  urethra  and  with 
a  straight  blunt-pointed  knife  or  a  meatotome  (fig.  174)  incise 
the  meatus  and  about  half  an  inch  down  the  urethra  until  a 
No.  30  French  sound  can  be  easily  passed.  It 'is  well  to  remem- 
ber that  after  healing  the  size  of  the  meatus  will  be  two  or 
three  numbers  smaller  than  what  it  was  originally  cut  to.  To 
stop  the  bleeding  after  the  incision  the  same  urethral  plug  can 
be  introduced  that  was  used  before  the  incision  and  counter- 
pressure  made  on  it  over  the  frenum.      The  patient  should  be 


Fig.  174. — Otis'  meatotome. 

loaned  a  short  straight  sound  made  for  the  one  purpose,  with 
instructions  to  introduce  it  three  times  daily  for  three  or  four 
days  to  keep  the  cut  open,  or  otherwise  it  may  grow  together 
again.  The  incision,  it  is  hardly  necessary  to  remark,  should  be 
made  on  the  floor  of  the  urethra  toward  the  frenum.  Instead  of 
using  the  cotton  plug  with  cocain  a  few  drops  of  the  latter  can 
be  injected  into  the  frenum. 

Stricture  of  the  Urethra 
Symptoms. — A  stricture  of  quite  small  caliber  may  sometimes 
be  present  without  exhibiting  any  manifestations  of  its  existence. 
Such  patients  may  complain  of  pain  on  urination  and  frequency, 
particularly  during  the  day.  Prostatic  cases,  on  the  other  hand, 
are  likely  to  be  troubled  by  frequency  of  micturition  occurring  at 
night  or  toward  morning.  A  slight  discharge  from  the  meatus 
often  accompanies  stricture,  and  it  is  often  the  cause  of  a  relapsing 
urethritis.  It  is  frequently  associated  with  some  disturbance  of  the 
sexual  function.  In  stricture  the  caliber  of  the  stream  is  influenced 
to  a  greater  or  less  degree  by  the  extent  of  the  stricture.  Thus  it 
may  be  but  little  diminished  or  may  be  forked;  there  may  be 
dribbling  after  urination,  and  in  a  stricture  of  very  small  caliber 


PLATE  XIII 


Stricture  of  posterior  porticm  of  pendulous  urethra  following  chronic  gonorrhea 
and  showing  secondar^^  distention  of  the  prostatic  urethra. 


COMPLICATIONS  455 

the  patient  will  pass  a  thread-like  stream,  not  infrequently  tinged 
with  blood;  in  strictures  that  cause  almost  complete  occlusion 
only  a  few  drops  at  a  time  can  be  passed,  the  effort  being  attended 
with  much  pain  and  difficulty.  The  form  of  the  stricture  can  be 
perfectly  shown  only  by  practising  intra-urethral  instrumentation. 

Location. — The  majority  of  strictures  occur  in  the  membra- 
nous urethra,  and  practically  all  that  need  operative  interference 
are  found  theres  those  occurring  in  the  anterior  urethra,  with 
but  few  exceptions,  are  capable  of  being  dilated. 

Treatment. — The  treatment  of  stricture,  like  the  treatment  of 
hypertrophy  of  the  prostate,  will,  in  the  future,  be  largely  of  the 
preventive  form.  In  the  section  on  the  pathology  of  this  con- 
dition it  was  shown  that  true  stricture  is  the  formation  of  scar 
tissue  at  the  base  of  a  granulomatous  lesion.  It  may  be  assumed 
that  if  urethritis  were  so  treated  that  no  granulation  tissue 
formed,  true  stricture,  which  is  made  up  of  resulting  scar  tissue, 
would  not  occur.  Unfortunately,  through  either  unwise  treat- 
ment or  neglect,  scar  tissue  does  follow  urethritis  in  a  very 
large  proportion  of  cases.  Quite  often,  however,  these  scars  are 
so  small  that  they  never  give  rise  to  any  apparent  symptoms. 

For  diagnostic  purposes,  when  the  stricture  is  not  a  very  tight 
one,  an  ordinary  olive-pointed  bougie  having  a  circumference  of 
No.  1 6  or  1 8  French,  will  prove  a  useful  instrument.  If  the 
bougie  passes  into  the  bladder  easily,  and  then  shows  a  tendency 
to  pop  out,  because  of  the  good  contractile  power  of  the  com- 
pressor urethrae  muscle,  the  probabilities  are  that  no  stricture 
of  particular  consequence  exists,  either  in  the  anterior  or  in  the 
posterior  urethra.  Often  small  masses  will  be  encountered  in 
the  anterior  urethra  as  the  olive  point  sHdes  down  the  surface. 
These  are  very  likely  to  be  granulomata,  particularly  if  chronic 
•  urethritis  is  present ;  they  are  commonly  known  as  soft  stric- 
tures, and  have  been  mentioned  and  illustrated  elsewhere.  If  a 
more  definite  examination  of  the  anterior  urethra  is  to  be  made, 
a  rubber  bougie  a  boule  may  be  used.  The  largest  one  possible 
should  be  made  to  shp  by  the  obstruction;  when  the  next  one 
larger  fails  to  pass,  the  caliber  of  the  stricture  may  be  estimated. 
A  very  useful  instrument  for  the  purpose  of  measuring  the  di- 
ameter of  the  anterior  urethra  is  the  urethrometer  of  the  late  Dr. 
Fessenden  D.  Otis,  previously  illustrated.      If  it  is  desired,  the 


456  DISEASES    01?   THE    MALE    URETHRA 

anterior  urethra  may  be  inspected  with  the  endoscope  in  order  to 
observe  whether  granuloma  or  true  stricture  is  present.  The  gran- 
ulomatous infiltrations  are  benefited  by  any  measure  that  stimu- 
lates circulation  through  the  parts  without  unduly  irritating  them, 
such  as  pressure  by  means  of  bougies  or  steel  sounds  or  by  the  use 
of  the  straight  Kollmann  dilator;  if  the  infiltrations  are  situated 
at  the  bulbomembranous  junction,  the  curved  Kollmann  dilator 
should  be  used.  These  cases  of  stricture  should,  when  possible,  be 
kept  under  observation  for  some  time,  and  dilation  should  be  per- 
formed about  once  a  week.  The  granulomatous  infiltrations  will 
also  disappear  under  stimulating  irrigations,  such  as  silver  nitrate, 
without  pressure  being  used.  The  foregoing  remarks  have  refer- 
ence only  to  the  treatment  of  strictures  of  a  caliber  that  will  admit 
a  No.  12  sound  or  one  of  large  diameter.  These  strictures  are 
rarely  seen  without  some  accompanying  chronic  inflammatory 
condition  of  the  urethra,  and  are  best  treated  not  only  by  dis- 
tention, but  by  irrigations  as  well.  As  a  rule,  several  processes 
are  going  on  at  one  time  in  the  same  urethra.  Divulsion  should 
never  be  performed;  this  method  of  tearing  a  stricture  apart  by 
means  of  special  instruments  devised  for  the  purpose  has  been 
productive  of  much  harm.  The  old-fashioned  instruments  used 
for  this  purpose  served  as  a  model  from  which  the  Kollmann 
dilator  was  evolved,  an  instrument  that,  when  properly  used, 
will  be  found  of  great  value.  Kollmann  dilators  are  procurable 
in  three  forms:  The  straight,  which  are  used  for  the  anterior 
urethra;  the  curved,  with  the  prostatic  curve,  for  the  deep 
urethra,  and  covered  with  rubber;  and  curved  for  the  deep 
urethra,  which  are  intended  for  irrigation  at  the  same  time,  and 
that  are  not  covered  with  rubber.  The  writers  prefer  the  curved 
that  are  covered  with  rubber.  Irrigations  can  be  performed 
through  a  small  silk  catheter  immediatelv  after  passing  the  Koll- 
mann dilator  or  at  a  subsequent  visit.  In  individuals  with  sensi- 
tive urethras  it  is  better  to  postpone  irrigation  after  dilation  to  a 
subsequent  visit.  Undoubtedly  in  the  past  many  of  the  masses 
of  granulations  mentioned  have  been  incised  under  the  classifica- 
tion of  "urethrotomy  for  strictures  of  large  caliber,"  an  opera- 
tion which  has  to  a  great  extent  passed  out  of  use.  While  in 
very  exceptional  cases  it  may  have  been  productive  of  good 
results,  it  often  caused  harm,  generally  by  causing  after-deformi- 


COMPUCATIONS 


457 


ties  of  the  penis.     Dilation  is  as  useful  for  true  stricture  as  it  is 
for  the  granulomatous  masses;  only  true  scar  formation  yields 
less  readily  to  treatment.     When  the  true  strictures 
are  not  too  tight,  the  same  general    rules  should 
apply  as  in  the 
dilation   of  the 
softer  variety. 
A  stricture 


Fig.  175— Koll- 
mann's  straight  di- 
lator. 


Fig.  176.  — Koll- 
mann's  dilator  for 
posterior  uretlira, 
witli  irrigating  at- 
tachment. 


Fig  177-  — KoU- 
mann's  double 
curved  dilator  for 
posterior  urethra. 


Fig.  178.  —  Koll- 
mann's  curved  artic- 
ulated dilator  with 
Beniques  curve  for 
posterior  urethra. 


that  has  been  so  widely  dilated  that  it  will  admit  a  Kollmann 
dilator,  of  the  caliber  of  No.  20  French,  may  be  stretched  until  a 
sense  of   resistance   is  felt  and  the  patient  complains  of   pain. 


458  DISEASES    OF   THE    MALE    URETHRA 

or  until  the  index  has  been  screwed  up  ordinarily  two  or  three 
points  from  the  caliber  which  it  had  reached  on  a  previous 
visit.  Under  any  one  of  these  conditions  distention  should  not 
be  carried  further.  The  dilator  should  not  be  allowed  to  re- 
main in  the  urethra  for  more  than  ten  minutes.  Strictures  of  the 
anterior  urethra  proper  rarely  produce  harm  in  themselves,  and 
they  can,  as  a  rule,  be  very  rapidly  dilated.  After  the  urethra  has 
been  dilated  to  No.  40  or  42  French  by  the  Kollmann  dilator,  or 
so  widely  that  it  will  admit  a  No.  32  or  33  French  sound  with  com- 
parative ease,  the  stricture  may  be  considered  cured  so  far  as 
distention  is  concerned.  The  chronic  urethritis  accompanying 
the  condition  may,  however,  require  further  treatment  in  the 
form  of  irrigations.  In  any  case  the  patient  should  be  advised  to 
report  three  or  four  times  a  year  in  order  that  any  tendency  to 
further  stricture  formation  may  be  detected. 

.  In  using  the  Kollmann  dilator  for  the  deep  urethra  when  it  is 
desired  to  dilate  the  bulbous  more  than  the  posterior  urethra, 
the  handle  of  the  instrument  should  be  somewhat  elevated.  To 
dilate  the  bulb  while  stricture  exists,  the  instrument,  still  expanded 
to  the  extent  that  will  not  cause  too  much  inconvenience  to  the 
patient,  should  be  slowly  withdrawn  from  the  urethra.  True 
cicatricial  strictures  are  probably  not  much  benefited  until  dilated 
beyond  30.  Once  the  Kollmann  instrument  has  been  introduced 
by  the  surgeon,  the  patient  may,  if  desirable,  perform  the  dilation 
himself.  The  procedure  may  consume  ten  minutes,  the  instru- 
ment remaining  in  place  a  few  minutes  at  full  dilation.  Irrigations 
may  be  used  after  or  between  the  dilations.  The  treatment 
should  extend  over  a  period  of  at  least  three  months,  dilation 
being  performed  at  intervals  of  a  week  in  the  case  of  old  persons; 
young  and  middle-aged  patients  with  true  stricture  may  allow- 
longer  intervals  to  elapse  between  dilations  without  giving  any 
evidence  of  recontraction.  After  a  certain  stage  of  the  treatment 
has  been  reached,  especially  with  the  latter  class  of  patients,  the 
urethra  will  generally  remain  well  dilated  for  months  or  a  year 
without  requiring  further  instrumentation.  It  is  a  good  plan,  in 
dilating  for  stricture,  occasionally  to  observe,  by  means  of  the  endo- 
scope, the  eflfects  of  the  instrumentation  on  the  urethra.  A  change 
from  a  whitish  or  grayish  to  a  pinkish  color  is  a  good  indication. 
For    performing    thorough    dilation    a   silk   bougie,    the    steel 


COMPLICATIONS  459 

sound,  or  the  Kollmann  dilator  may  be  nsed.  For  dilation  up 
to  No.  20  F.  the  best  instrument  to  use  is  the  silk  bougie;  be- 
yond that  the  steel  sound  or  the  Kollmann  dilator  should  be 
employed.  During  the  last  few  years  the  writers  have  used  the 
Kollmann  dilator  more  and  more  in  private  practice,  and  have 
almost  entirely  discarded  the  steel  sound.  In  using  steel  sounds 
above  No.  20  F.  care  should  be  observed  to  choose  conically 
pointed  sounds  rather  than  the  blunt  ones  so  often  placed  on  the 
market.  It  is  not  advisable,  ordinarily,  to  pass  more  than  two 
or  three  sounds  at  one  sitting.  Such  sounds  may  gradually 
increase  one  to  three  numbers  in  diameter. 

Treatment  for  Retention  oe  Urine  and  of  Tight,  Im- 
passable Stricture 

In  examining  a  patient  who  is  unable  to  urinate  or  who  voids  a 
very  small  stream  with  much  difficulty,  it  should  be  remembered, 
before  making  any  examination,  that  if  the  patient  is  old  and  gives 
a  history  of  gradually  increasing  urinary  difficulties,  the  retention 
is  very  probably  due  to  enlargement  of  the  prostate.  If  the  man  is 
of  middle  age  or  younger,  particularly  if  he  has  been  very  careless 
or  dissipated,  the  probabilities  of  the  urinary  difficulties  being  due 
to  stricture  are  much  stronger.  When  retention  occurs  as  a  com- 
plication of  acute  urethritis,  it  is  due  to  intense  swelling  of  the 
walls  of  the  urethra,  and  true  stricture  is  often  absent. 

Hot  sitz-baths  and  efforts  to  urinate  under  hot  water  in  a  bath- 
tub, the  water  covering  almost  the  entire  body,  will  generally 
facilitate  the  flow  of  urine.  Such  measures  should  be  given  a 
fair  trial  in  the  effort  to  overcome  a  recent  attack  of  retention 
before  instruments  are  made  use  of. 

Whatever  be  the  conditions  suspected,  it  is  well,  in  making  an 
examination,  first  to  attempt  to  pass  an  ordinary  olive-pointed, 
very  flexible  tipped,  French  silk  catheter  of  a  caliber  of  about  No. 
16  or  18.  If  it  meets  with  an  obstruction,  as  it  very  often  will, 
at  the  bulbomembranous  junction,  three  points  are  to  be  con- 
sidered— whether  we  are  dealing  with  stricture,  with  an  enlarged 
prostate,  or  with  spasmodic  stricture  due  to  nervousness.  Spas- 
modic strictures  are  generally  quite  easily  recognized  by  any  one 
who  has  considerable  clinical  experience  in  the  treatment  of 
urethral  disorders,  but  the  inexperienced  practitioner  will  some- 


460  DISEASES    OF    THE    MALE    URETHRA 

times  find  them  quite  confusing.  If  it  is  suspected  that  the 
inabihtv  to  enter  the  bladder  and  the  obstruction  at  the  bulbo- 
membranous  junction  of  the  urethra  are  due  to  a  spasm  of  the 
compressor  urethrse  muscle,  a  steel  sound,  a  few  sizes  larger  than 
the  catheter  previously  mentioned,  may  be  inserted,  remembering 
that  by  making  slight  gentle  pressure  at  the  bulbomembranous 
junction  spasm  may  almost  always  be  overcome.  This  failing, 
an  attempt  should  be  made  to  overcome  the  spasm  by  injecting 
a  considerable  quantity  of  warm  water  through  a  soft  catheter 
carried  as  far  as  the  seat  of  the  occlusion.  If  this  irrigation 
through  the  catheter  is  continued  for  some  time, — ten  or  fifteen 
minutes, — it  will  generally  be  possible,  then,  after  the  catheter 


Fig.  179. — Mercier's  elbowed  metal  catheter. 

has  been  removed,  to  pass  an  instrument  into  the  bladder  if  the 
constriction  was  really  due  to  spasm.  If  an  obstruction  is  present 
that  hinders  the  passage  of  a  small  olive-pointed  bougie  and  not 
due  to  spasmodic  occlusion,  this  is  due  to  one  of  two  conditions — 
stricture  or  retention  caused  by  an  inflamed  hypertrophied  pros- 
tate. If  due  to  hypertrophy  of  the  prostate,  this  is  generally  made 
clear  by  the  history  of  the  case,  the  age  of  the  patient,  and  the 
marked  rectal  enlargement  of  the  prostate  that  is  to  be  felt.  In 
such  cases,  which  are  comparatively  rare,  but  which  do  occasion- 
ally occur,  the  urethra  takes  a  different  curve  from  the  normal, 
and  it  is  for  this  reason  that  the  ordinary  catheter  will  often  not 
enter  the  bladder,  necessitating  the  use  of  a  catheter  of  a  particular 
curve.  The  Mercier  curve,  which  is  to  be  had  in  steel  or  rubber  cath- 
eters, will  generally  prove  effective.  This  failing,  a  steel  catheter 
with  a  large  prostatic  curve  may  be  used ;  if  this  too  proves  unsuc- 
cessful, a  bicoude  curved  catheter  may  be  used.  It  is  the  writers' 
custom  to  keep  on  hand  a  series  of  these  three  catheters.  They 
are  extremely  useful  at  times  if  the  retention  is  due  to  enlarged 
prostate.  After  the  catheter  has  entered  the  bladder,  that  organ 
may  be  emptied  and  washed  out.     The  advisability  of  an  imme- 


COMPLICATIONS 


461 


diate  operation  should  now  be  considered,  or  another  catheter 
may   be   passed   in   a  few   hours'    time.      These 
cases   have  been  more   fully   dealt   with  in   the 
chapter  on  Diseases  of  the  Prostate. 

If  the  retention  is  not  due  to  prostatic  obstruc- 
tion, stricture  exists.  An  effort  should  first  be 
made  to  pass  the  stricture  with  some  instrument 
and  later  to  dilate  it.  For  passing  the  stricture 
the  following  procedure  may  be  adopted:  The 
urethra  is  filled  with  warm  oil  and  bougies  of 
gradually  decreasing  caliber  are  inserted  until  the 
filiform  bougies  are  reached.  By  the  exercise  of 
much  care  and,  patience  on  the  part  of  the  sur- 
geon the  vast  majority  of  cases  of  stricture  of 
small  caliber  may  be  passed  by  a  fiUform  bougie. 
When  one  bougie  has  been  passed,  an  attempt 
may  be  made  to  introduce  another  one  alongside 
of  it.  If  the  ordinary  whalebone  bougies  fail  to 
pass,  catgut  bougies,  which  are  still  finer,  may  be 
tried.  Some  urethras  are  so  long  that  a  bougie 
of  double  the  ordinary  length  may  be  required  to 
reach  the  bladder.  After  the  filiform  has  entered 
the  bladder,  in  cases  where  the  retention  is  not 
complete  and  the  patient  able  to  urinate  a  little, 
it  may,  if  desired,  be  tied  there  for  a  few  hours, 
at  the  end  of  which  time  a  very  small  bougie — 
one  larger  than  the  filiform,  however — can  usually 
be  substituted.  Not  infrequently  the  attempt 
is  made  to  enter  the  bladder  by  inserting  a  tun- 
neled steel  sound  of  the  smallest  caliber  over  the 
filiform. 

If  this  steel  sound  can  be  passed  into  the  bladder  over  the  fiH- 
form  acting  as  a  guide,  the  problem,  so  far  as  retention  is  concerned, 
is  generally  solved.  The  stricture  may  be  so  much  distended  by 
the  passing  of  larger  and  larger  tunneled  sounds  over  the  filiform 
that  after  a  short  time  a  catheter  may  be  forced  in  and  the  bladder 
emptied. 

The  after-treatment  will  consist  of  rest  in  bed,  the  use  of  uri- 
nary antiseptics  internally,  and  gradual  distention  by  means  of 


Fig.  180. — Gou- 
ley's  tunneled  sound 
and  guide. 


462  DISEASES    OF    THE    MALE    URETHRA 

steel  sounds,  larger  and  larger  ones  being  passed  at  intervals  of 
every  four  or  five  days.  If  it  is  found  impossible,  by  any  of  the 
means  described,  to  get  the  best  of  the  stricture,  the  situation 
becomes  somewhat  more  perplexing;  in  similar  cases  the  writers 
have  found  the  use  of  a  certain  instrument  to  be  of  great  value. 
This  is  a  modification  of  the  long,  whip-like  filiform  known  a? 
the  Banks  bougie.  This  bougie  is  extremely  small  at  one  end, — 
the  size  of  the  smallest  filiform, — and  gradually  grows  larger  so 
that  toward  the  upper  end  it  has  a  diameter  of  a  No.  10  French. 

The  objection  to  Banks' 
bougie  is  that,  being  made 
of  whalebone,  is  it  some- 
what rigid;  to  overcome 
this,  one  of  the  writers  had 
a  bougie  of  similar  shape 
made  of  vulcanized  rubber. 
This  is  much  more  flexible 


^ 


„.     0      i>  •  *    f  r-    1    -     u  ^  u         -A  than  the  original  form,  and 

Fig.  181. — Points  of  Gouley  s  whalebone  guides.  o  ' 

has  repeatedly  proved  suc- 
cessful where  other  instruments  have  failed;  for,  if  the  end 
will  pass  the  stricture,  it  is  only  necessary  to  continue  pushing. 
The  lower  portions  of  the  shaft  will  double  up  as  it  enters  the 
bladder,  without  doing  any  harm,  so  it  may  be  pushed  on  until 
the  full  diameter  of  the  shaft  is  engaged  in  the  stricture.  After 
withdrawal,  it  is  comparatively  easy  to  pass  a  small  ordinary  silk 
bougie  and  so  continue  distention.  It  is  always  well  to  attempt 
to  pass  this  instrument  before  resorting  to  filiforms. 

In  our  experience,  almost  invariably  if  a  filiform  has  once  been 
passed  and  tied  in  for  several  hours,  this  whip  bougie  can  be  passed 
and  the  following  treatment  of  the  case  much  simplified.  Very 
rarely,  since  this  instrument  was  manufactured,  at  our  suggestion, 
about  ten  years  ago,  have  we  found  it  necessary  to  use  the  tunnel 
sound.  In  our  experience,  when  in  possession  of  the  former,  the 
latter  instrument  is  practically  no  longer  required  for  the  purpose 
of  distention  of  stricture. 

In  cases  in  which  the  stricture  proves  impermeable,  it  is  well 
to  administer  an  anesthetic  and  then  repeat  the  attempt.  If 
this  also  proves  unsuccessful,  an  operation  is  necessary.  It  is 
rarely  necessary  to  operate  for  the  relief  of  stricture  when  filiforms 


COMPLICATIONS 


463 


can  be  passed.  This  is  a  rule  to  which  there  are  a  considerable 
number  of  exceptions,  generally  due  to  a  dense  formation  of  cica- 
tricial tissue,  or  to  the  fact  that  time  enough  cannot  be  taken  to 
dilate  the  stricture  in  a  proper  manner.  We  have  purposely  not 
attempted  to  classify  these  exceptions,  as  has  often  been  the  cus- 
tom in  the  past.  We  do  not  wish  to  encourage  the  unneccessary 
performance  of  operations,  and 
the  better  the  surgeon,  the  more 
often  can  strictures  be  overcome 
without  incision. 

It  is  not  considered  desirable 
or  necessary  to  give  here  a  re- 
view of  all  the  various  methods 
of  operating  for  the  relief  of 
stricture.  They  consist,  for  the 
most  part,  of  the  performance 
of  either  internal  or  external 
urethrotomy. 

Internal  urethrotomy  is  to 
be  performed  only  when  the 
stricture  is  at  the  bulbomem- 
branous  junction  and  when  a 
small  silk  bougie  that  acts  as  a 
guide,  and  later  on  doubles  up 
in  the  bladder,  the  end  of  the  in- 
strument being  attached  at  the 
upper  end  of  the  bougie,  can  get 
past  the  obstruction.  The  in- 
strument ordinarily  used  for  the 
purpose  is  called  the  Maison- 
neuve,  after  the  French  surgeon 
who  invented  it.  The  portion 
of  the  instrument  above  the  at- 
tachment to  the  filiform  consists 
of  a  curved  steel  sound  of  a  very 
small  caliber,  running  along  the  anterior  surface  of  which  is  a 
groove;  along  this  groove  runs  a  knife-blade  with  a  very  long 
handle,  which  projects  above  the  upper  border  of  the  instru- 


Fig.  182. — Greene's  whip  vulcanized  rub- 
ber bougie. 


464 


DISEASES    OF    THE    MALE    URETHRA 


merit.  The  filiform  guide,  followed  by  the  instrument  without 
the  knife,  having  been  pushed  into  the  bladder,  the  penis 
being  firmly  held  by  an  assistant  in  such  a  manner  that  the 
urethra  is  on  the  stretch,  the  knife-blade  is  introduced  at  the 
meatus  in  the  groove  of  the  instrument,  pushed  rapidly  down 
in  the  groove  be^^ond  the  bulbomembranous  junction,  and  as 
rapidly  withdrawn.  The  instrument  is  now  removed  and  a  some- 
what stiff,  olive-pointed  silk  catheter  of 
No.  10  or  12  caliber  is  passed  into  the 
bladder;  the  bladder  is  washed  out  through 
this,  and  the  instrument  is  then  tied  in 
place  by  means  of  tape  passed  around 
the  meatus,  being  allowed  to  remain  thus 
for  six  or  eight  hours,  in  order  that,  by 
the  pressure  it  exerts,  it  may  tend  to 
prevent  hemorrhage.  At  the  end  of  this 
time  the  bladder  should  again  be  w^ashed 
out  and  the  catheter  removed.  At  intervals 
of  every  three  or  four  days  the  stricture  may 
gradually  be  dilated  by  the  insertion  of 
sounds — either  rubber  bougie  or  steel  sounds 
of  larger  and  larger  diameter.  It  is  best  to 
use  the  silk  bougies  at  first,  and,  when  larger- 
sized  instruments  are  required,  the  steel 
sounds,  or  the  after-dilation  may  be  made 
by  the  Kollmann  dilator.  In  performing 
this  operation  it  is  wdser  to  use  the  smallest 
of  the  Maisonneuve  knives. 

Internal  urethrotomy  may  be  performed 
by  means  of  the  Maisonneuve  instrument, 
without  the  employment  of  general  anes- 
thesia, a  2  per  cent,  solution  of  cocain  be- 
ing instilled  two  or  three  times  and  allowed 
to  trickle  down  the  posterior  urethra  into 
the  bladder  and  remain  there.  The  Maison- 
neuve instrument  is  a  fairly  good  one,  and 
has  in  the  past  served  a  useful  purpose.  At  the  present  time  it 
is  rarely,  if  ever,  required  in  the  performance  of  an  internal  ure- 


Fig.  183. — Maisonneuve's 
urethrotome. 


COMPLICATIONS 


465 


W-v} 


throtomy,  for  if  a  stricture  will  admit  the  introduction  of  a  filiform 
bougie  into  the  bladder,  it  can  almost  invariably,  by  means  of 
tunneled  sounds  or  otherwise,  be  so  distended ,  that  no  cutting 
operation  will  be  required.  If  these  operations — either  external 
or  internal — for  the  relief  of  stricture  at  the  bulbomembranous 
jtmction  can  be  avoided,  it  should  be  done.  _ 

Although  the  death-rate  following  these  opera- 
tions is  comparatively  low,  and  is  probably 
growing  still  lower  each  year,  there  is  always 
some  danger,  which  should  be  considered,  of 
so  wounding  the  floor  of  the  prostatic  urethra 
as  to  render  a  hitherto  virile  man  impotent. 
It  was  often  the  custom  in  the  past  to 
incise  strictures  of  the  anterior  urethra, 
some  of  which  permitted  the  passage  of 
large  instruments — the  so-called  strictures 
of  large  caliber.  Many  thousands  of  such 
operations  were  performed.  In  quite  a  large 
proportion  of  cases  deformities  of  the  penis 
follow  the  making  of  too  deep  incisions  in  the 
anterior  urethra.  Such  operations  are  now 
performed  much  less  frequently  than  formerly. 
Many  ingenious  instruments  were  devised  for 
the  purpose.  That  of  the  late  Dr.  Fessenden 
S.  Otis  is  useful  for  this  operation,  which  is 
mentioned  here  not  because  it  is  practised  by 
the  writers  as  a  routine  procedure,  but  because 
they  consider  it  an  adjunct  to  external  urethro- 
tomy. Dr.  Otis'  urethrotome  carries  a  sheathed 
straight  knife  in  a  groove  cut  in  the  upper  end 
of  the  instrument,  A  dial-plate  registers  the 
amount  of  separation  effected  by  means  of  a 
screw  apparatus.  The  instrument  is  introduced 
and  passed  by  the  stricture  closed;  then  dis- 
tended. When  the  desired  caliber  is  reached, 
the   knife-handle  is  lifted,  which  releases  the   Fig.  184.— otis'  dilating 

urethrotome. 

knife  from  the  sheath,  when  it  can  be  brought 
up  across  as  much  of  the  urethra  as  it  is  desired  to  incise,  and 
30 


466  DISEASES    OF    THE    MALE    URETHRA 

then  pushed  back  into  the  sheath  and  the  instrument  removed 
from  the  urethra. 

External  urethrotomy  is  the  operation  generally  used  when 
one  is  required  for  the  reUef  of  stricture.  It  may  also  be  used  for 
other  purposes,  such  as  bladder  drainage,  prostatectomy,  and  the 
like.  This  operation  was  performed  more  often  in  the  past  than  it 
is  at  present,  and  undoubtedly  much  more  often  than  was  neces- 
sary in  the  attempt  to  overcome  tight  stricture  of  the  urethra. 
When  performed  with  a  guide — that  is,  when  the  operation  is 
done  for  the  relief  of  a  stricture  that  is  not  entirely  impassable — it 
consists  of  cutting  down  through  the  perineum  just  behind  the 
scrotum,  exactly  in  the  median  line,  upon  an  instrument,  ordinarily 
a  small  grooved  steel  sound,  which  has  been  pushed  into  the  bladder 
or  a  filiform  bougie. 

The  patient  being  anesthetized  and  the  operative  toilet  having 
been  made,  the  legs  are  elevated,  the  testicles  pulled  up  out  of 
the  way,  and  the  bulbomembranous  region,  with  the  aid  of  an 
assistant  holding  a  guide,  being  rendered  as  tense  as  possible 
over  the  instrument  in  the  bladder,  the  incision  is  made  in  the 
manner  previously  directed,  directly  over  the  curve  of  the  instru- 
ment in  the  bladder,  which  can  be  felt ;  it  should  be  kept  exactly 
in  the  median  line  and  parallel  to  the  shaft  of  the  penis,  and  should 
be  about  two  inches  long.  The  dissection  should  then  be  carried 
carefully  down  until  the  urethra  is  met.  By  keeping  the  thumb 
and  finger  of  the  free  hand  on  each  side  of  the  cut  hemorrhage 
will  be  largely  prevented.  Any  bleeding  points  encountered 
may  be  tied  off  as  the  operation  progresses. 

The  urethra,  it  must  be  remembered,  if  dissected  out  from  the 
body  of  the  penis,  closely  resembles  in  appearance  a  piece  of  half- 
cooked  macaroni;  being  densely  surrounded  by  tissue  in  the 
perineum,  it  does  not,  however,  at  first  assume  this  appearance 
when  cut  down  upon  with  the  knife,  but  if  the  dissection  proceeds 
slowly  and  carefully  and  the  knife-handle  is  frequently  used  to 
push  the  other  tissue  out  of  the  way,  it  is  generally  fairly  easy, 
even  for  an  inexperienced  surgeon,  to  determine  when  the  urethra 
is  reached.  Having  been  encountered,  the  urethra  should  be 
carefully  incised  for  an  inch  or  two  from  above  downward,  a  liga- 


COMPLICATIONS  467 

ture  being  placed  on  each  side  and  given  to  an  assistant  to  hold, 
so  as  to  keep  the  incision  in  the  urethra  open ;  an  attempt  may 
then  be  made  to  examine  the  urethra  further.  When  a  stric- 
ture is  present,  this  cannot  be  done,  as  the  guide  that  has  been 
placed  in  the  bladder  will  become  tightly  engaged  in  the  stricture. 
This  being  the  case,  Arnott's  grooved  probe  director  should  be 
pushed  along  the  bottom  of  the  guide,  which  may  be  seen  running 
into  the  bladder,  the  groove  of  the  instrument  pointing  downward ; 
then  a  small,  narrow-bladed  knife  or  a  Gouley's  beaked  bistoury 
should  be  run  along  the  groove  in  the  director  until  the  constrict- 
ing bands  have  been  severed.  If  a  grooved  sound  has  been  used 
for  a  guide,  the  knife  may  be  run  along  the  groove  in  the  sound. 
In  cutting  the  constricting  band  it  is  possible  for  an  inexperienced 
operator  to  wound  the  rectum.  It  is  well,  at  this  point  of  the 
operation,  to  introduce  a  finger  in  the  rectum  in  order  to  learn  if 
the  knife  is  approaching  too  closely.  The  incision  having  been 
made,  the  knife  should  be  withdrawn,  followed  by  the  director; 
then  the  guide,  which  has  been  run  down  the  urethra  into  the 
bladder,  should  be  removed,  and  the  forefinger  of  the  operator 
introduced  through  the  perineal  wound  into  the  bladder.  As  a 
rule,  when  the  bladder  is  reached,  this  will  be  made  manifest  by  the 
urine  that  will  flow  out  of  the  wound  after  the  incision  is  made  in 
the  urethra  through  the  stricture,  and  urethra  depressed.  Before 
or  after  the  guide  has  been  withdrawn,  and  after  the  incision  has 


Fig.  185. — Teale's  probe-pointed  gorget. 


been  made  in  the  urethra  along  the  director  and  the  director  re- 
moved, a  Teale  probe-pointed  gorget  may  be  run  along  the  ure- 
thra until  the  bulbous-pointed  end  reaches  the  bladder.     Although 


468  DISEASES   OF   THE    MALE    URETHRA 

this  is  not,  of  necessity,  the  instrument  to  use,  ordinarily  it  makes 
a  good  tunnel  along  which  the  bladder  may  be  reached.  Medical 
students  and  surgeons  in  general  will  find  it  an  advantage  to 
familiarize  themselves  with  the  feel  of  the  prostatic  urethra  as 
imparted  to  the  examining  finger.  So  far  as  this  is  concerned, 
when  the  urethra  enters  the  prostate,  the  finger  running  along  the 
canal  feels  as  if  it  had  entered  the  neck  of  a  bottle  or  as  if  it  were 
entering  the  slightly  distended  cervix  uteri.  From  the  fact  that 
many  of  the  cases  that  require  an  external  urethrotomy  are  riddled, 
as  it  were,  with  scar  tissue  along  the  bulb  and  pendulous  urethra, 
it  is  good  practice,  the  writers  believe,  when  the  bladder  has  been 
reached  and  the  stricture  incised,  etc.,  to  insert  in  such  cases  an 
Otis  urethrotome,  previously  described,  pushing  it  down  closed 
through  the  urethra  from  the  meatus  until  its  end  projects 
through  the  perineal  wound;  then,  opening  it  until  the  index 
points  to  the  desired  diameter, — 32  or  33, — in  the  manner  pre- 
viously described,  withdrawing  it  along  the  anterior  urethra 
as  far  as  may  seem  desirable — possibly  all  the  way  out.  A 
No.  30  French  sound  should  now  be  introduced  from  the  meatus 
downward  and  allowed  to  emerge  through  the  perineal  opening. 
If  it  passes  easily,  the  strictures  have  probably  been  incised 
far  enough.  If  the  gorget  was  used,  it  should  be  withdrawn 
from  the  perineal  wound  and  a  soft-rubber  catheter  of  large 
caliber  introduced  into  the  wound  and  run  along  into  the 
bladder.  Care  should  be  taken  that  this  does  not  press  too  hard 
against  the  posterior  wall  of  the  bladder,  and  also  that  its 
farthest  end  is  so  far  to  the  front  as  to  prevent  urine  or  any 
fluid  injected  through  it  into  the  bladder  from  escaping.  It 
can  be  fastened  in  by  means  of  tapes  tied  about  it,  run  around 
the  body  in  an  over-and-under  fashion,  or  two  or  three  catgut 
ligatures  may  be  inserted  through  the  skin  of  the  perineum  and 
piercing  the  wall  of  the  drainage-tube.  Before  the  tube  is  fastened 
in  place, — and  this  cannot  be  insisted  upon  too  strongly,  whether 
or  not  there  is  hemorrhage, — narrow  gauze  should  be  packed 
around  the  tube — that  portion  of  it  which  is  in  the  urethra. 
The  packing  may  be  removed  and  not  replaced  in  twenty-four 
or  forty-eight  hours,  and  the  tube  at  the  end  of  four  days;  if  de- 


COMPLICATIONS  469 

sired,  it  may  again  be  inserted  and  allowed  to  remain  for  three  or 
four  days  longer.     The  bladder  should  be  washed  out  daily  through 
the  tube,  and  before  and  after  the  tube  is  removed  considerable 
attention  should  be  paid  to  keeping  the  dressing  and  the  borders 
of  the  perineal  wound  clean.     By  means  of  a  little  glass  tube  a 
small  piece  of  rubber  tubing  can  be  attached  to  the  perineal  tube 
and  the  urine  allowed  to  drain  off  into  some  convenient  recep- 
tacle.    At  the  end  of  four  days,  when  the  tube  is  removed,  a  No. 
30  sound  should  be  gently  passed  into  the  bladder.     If  its  end 
engages    in    the    perineal    wound,    a   finger    introduced    in    the 
wound  will  guide  its  beak  onward  into  the  bladder.      A  cath- 
eter should  be .  reintroduced  about  every  four  days,   and,  ordi- 
narily, within  a  few  days   after   the   removal  of    the   tube    the 
patient    will    gradually    become    able    to    urinate    through    the 
meatus. 

It  sometimes  happens  that  a  filiform  can  be  introduced  into 
the  bladder,  but  that,  on  account  of  the  density  of  the  cicatricial 
tissues,  a  steel  guide  or  tunneled  sound  cannot  be  passed.     In 
such  a  case  pass  a  small  tunneled  sound  over  the  filiform  as  far 
down  the  urethra  as  it  will  pass;   it  will  generally  go  pretty  well 
down  to  the  bulb;   make  an  incision  in  the  median  fine  just  over 
its  extremity  or  just  below  it  until  the  fiHform  is  reached;   then, 
using  care  not  to  disturb  the  end  of  the  filiform  that  is  in  the 
bladder,  pull  the  other  end  out  through  the  perineal  wound ;  then 
take  a  Rand  tunneled  knife,  run  the  end  of  the  filiform  through 
the  opening  in  it,  and  push  the  knife  through  the  constricting 
bands.     After  the  stricture  has  been  cut  and  the  knife  and  filiform 
removed,   a  Teale  gorget  can  be  passed  into  the  bladder.     In 

making  the  incisions  use  care  to  avoid 
:^^______       cutting   the   filiform.      This    is    Rand's 

modification  of  Gouley's  operation.    We 


Immmmummmmm'ttmf^'mM^'t 


Fig.  186. — Rand's  tunneled  knife  for  incision  of  stricture. 

consider  the  Rand  tunneled  knife  a  good  modification,  from  the 
fact  that  in  a  very  tight  stricture  we  have  found  the  stricture  hug 


470  DISEASES    OF    THE    MALE    URETHRA 

the  filiform  so  tightly  that  after  the  perineal  incision  it  was  diffi- 
cult to  pass  anything  between  the  filiform  and  the  stricture. 

When  it  is  impossible  to  pass  any  instrument  as  a  guide,  through 
a  stricture,  it  becomes  necessary  to  do  an  external  urethrotomy 
without  a  guide.  This  is  a  somewhat  more  difficult  procedure, 
and  one  that  has  been  widely  discussed  in  the  past.  It  is  not 
always  easily  and  rapidly  performed,  even  by  experienced  opera- 
tors. It  should  be  remembered,  however,  that  the  surgery  of 
the  urethra  is  a  much  more  familiar  subject  than  it  was  ten  or 
twenty  years  ago.  Nothing  is  to  be  gained  by  undue  haste; 
on  the  other  hand,  however,  more  serious  consequences  are  likely 
to  result  from  a  too  prolonged  retention  of  urine  than  from  the 
operator  making  a  few  unnecessary  nicks.  It  is  also  well  to 
remember  that  a  suprapubic  cystotomy  is  a  comparatively  simple 
operation  to  perform;  that,  the  bladder  being  opened,  a  catheter 
or  guide  may  be  introduced  from  the  bladder  along  the  urethra 
forward,  the  perineum  being  incised  to  meet  it,  and  in  this  way 
the  stricture  be  overcome. 

Urethrotomy   is    performed   as    follows:    A   Wheelhouse   staff 
should     be    passed 
along    the    urethra 
as  far  as  it  will  go, 

the       crook       in       its  Fig.  187.— Wheelhouse's  staff. 

bulbous  end  point- 
ing outward.  The  perineal  incision  should  be  made  over  this,  and 
a  ligature  passed  through  the  urethra  on  each  side,  these  being  held 
by  an  assistant;  the  Wheelhouse  staff  should  then  be  turned 
around  and  hooked  into  the  upper  angle  of  the  wound.  A  tri- 
angular opening  is  thus  made  close  to  the  site  of  the  stricture. 

The    Wheelhouse    staff 
^^^^^^.,..^^ should  form   the  apex. 

Fig.  188.— Arnott's  grooved  probe.  HgatureS        holding       the 

wound  apart  at  the  cor- 
ners of  the  other  angles.  Now,  with  a  small  probe,  or,  better 
still,  an  Arnott's  probe-pointed  director,  push  gently  along  into 
the  wound,  when,  in  a  large  proportion  of  the  cases,  a  urethral 
opening  will  be  found.     If  this  is  the  case,  an  incision  should  be 


COMPLICATIONS  47 1 

made  with  a  small,  narrow-bladed  knife  along  the  probe  or  director 
that  has  found  the  opening,  and  the  stricture  incised.     The  re- 
maining steps  of  the  op- 
eration are  the  same  as 
those  ordinarily  pursued 
in  performing   external  ^.  '     ,    ,  ^    ,   j^. 

"■  ^  Fig.  189. — Gouley  s  beaked  bistoury. 

urethrotomy. 

A  surgeon  not  familiar  with  the  field,  on  operating  for  stricture 
without  a  guide,  will  be  surprised  at  the  small  size  of  the  opening 
of  the  stricture  ordinarily  present  in  cases  requiring  the  above 
operation.  The  urethra  having  been  incised,  held  up  at  its  apex, 
and  pulled  apart  by  the  sutures  on  the  side  in  the  manner  suggested 
above,  will  present  a  lozenge-shaped  surface  to  the  eye  of  the 
observer,  some  one  or  two  inches  long,  according  to  the  length  of 
the  incision  which  has  been  made  in  it.  In  the  face  of  this,  the 
opening  of  the  stricture  must  be  looked  for  very  carefully.  In 
our  experience  it  is  more  apt  to  be  found  toward  the  upper  angle 
of  the  wound,  and  when  perceptible  to  the  naked  eye,  exactly 
resembles  the  opening  of  one  of  Morgagni's  crypts,  as  seen  in  the 
anterior  urethra.  This  explanation  is  made  for  the  benefit  of 
those  who  have  not  had  experience  in  this  operation,  and  who, 
without  such  experience,  might  naturally  be  looking  for  an  opening 
with  a  larger  mouth  than  is  apt  to  be  present. 

If,  after  patient  effort,  the  operator  does  not  succeed  in  finding 
the  urethral  opening,  he  should  not  become  discouraged.  He 
must  remember  that  he  is  searching  for  the  end  or  some  other  por- 
tion of  a  white,  macaroni-like  tube,  which  issues  from  a  structure 
resembling  the  neck  of  a  bottle,  runs  toward  him,  and  the  end  of 
which  is  very  close  to  the  wound.  If  he  so  desires,  by  placing 
his  hand  on  the  abdomen  and  pushing  down,  or  by  having  an 
assistant  do  so,  the  neck  of  the  bladder  may  be  brought  a  little 
nearer  to  him.  A  dissection  should  then  be  made,  always  keeping 
in  the  median  line,  and  being  careful  not  to  wound  the  rectum. 
The  perineal  wound  should  be  extended  and  the  incision  be  made 
deeper  and  deeper  and  a  little  farther  down  toward  the  back. 
If  no  deflection  is  made  from  the  median  line,  the  urethra  is  very 
certain  to  be  reached  by  this  procedure.     A  small  trocar  may  be 


472  DISEASES   OF   THE    MALE    URETHRA 

introduced  to  reach  just  back  of  the  stricture.  If  urine  escapes 
after  the  stilet  has  been  withdrawn,  the  perineal  incision  may 
be  extended  to  it.  Dr.  C.  h.  Gibson,  of  New  York,  has  suggested 
that  a  hook  be  introduced  into  the  rectum,  the  prostate  hooked, 
and  that  then,  by  exerting  traction  downward  and  backward, 
the  urethra  will  be  stretched  and  more  easily  made  out  and 
reached  through  the  perineum.  With  one  finger  in  the  rectum, 
a  stab-hke  puncture  may  be  made  through  the  perineum  over 
the  seat  of  the  stricture,  and  the  knife-blade  pushed  forward 
toward  the  region  of  the  neck  of  the  bladder,  the  finger  in  the 
rectum  being  kept  at  the  apex  of  the  prostate  to  act  as  a  guide. 
The  stricture  may  be  incised  anteriorly  later. 

Other  methods  failing,  two  procedures  yet  remain  to  be  tried: 
suprapubic  cystotomy  with  retrograde  catheterization  and  the 
exposure  of  the  urethra  through  the  Senn  incision,  described 
further  on  as  a  method  for  reaching  the  prostate  and  the  seminal 
vesicles.  In  order  to  make  this  incision  it  is  only  necessary  to 
extend  the  perineal  wound  a  little  nearer  to  the  rectum,  and  then 
make  an  incision  from  the  end  of  the  perineal  wound  running  off 
from  each  side  of  the  rectum  at  an  angle.  The  rectum  being 
pulled  out  of  the  way  as  the  muscles  are  incised,  the  deep  urethra 
and  neck  of  the  bladder  will  be  brought  into  view ;  it  will  then  be 
possible  to  incise  the  urethra  at  the  desired  point. 

RUPTURE  OF  THE  URETHRA 
Rupture  of  the  urethra  is  the  result  of  accident  or  follows  a 
neglected  stricture ;  in  the  writers'  experience  it  is  most  frequently 
due  to  the  latter  cause  in  the  hospitals,  and  is  seen  in  old  alco- 
holics with  neglected  strictures  in  whom  infiltration  into  the 
siu-rounding  tissues  has  already  taken  place,  forming  a  brawny 
swelling  behind  the  ruptured  portion,  in  the  perineum,  along  the 
inner  surface  of  the  thighs,  and  possibly  on  the  abdomen,  over 
the  pubic  region.  When  urinary  infiltration  has  taken  place, 
sloughing  is,  of  course,  eventually  to  be  expected.  It  is  astonish- 
ing to  observe  how  extensive  an  amount  of  infiltration  of  urine 
into  the  surrounding  tissues  may  take  place  and  recovery  still 
follow. 


RUPTURE  OF  THE  URETHRA  473 

The  diagnosis  in  these  cases  is  comparatively  easy ;  the  swelling, 
with  the  history  of,  or  the  presence  of,  stricture,  pointing  to  rup- 
ture. These  cases  should  be  treated  as  certain  other  forms  of 
stricture — i.  e.,  by  external  urethrotomy;  for  although  the  ure- 
thra is  ruptured,  the  rupture  is  not  often  complete,  and  it  will 
generally  be  possible  to  pass  a  guide  into  the  bladder ;  free  drain- 
age of  the  infiltrated  surfaces  should  be  instituted.  It  is  some- 
times necessary  to  make  a  large  number  of  incisions.  A  case  of 
rupture  of  the  urethra  coming  imder  the  care  of  one  of  the  writers 
recovered  after  drainage-tubes  had  been  inserted  in  the  inner 
surface  of  the  thigh,  lower  portion  of  the  abdomen  and  groin, 
the  tubes  running  in  many  directions.  Recovery  may  follow 
even  in  those  cases  in  which  the  after- sloughing  is  so  extensive 
as  to  demand  a  plastic  operation  for  the  purpose  of  covering  the 
denuded  surfaces.  One  of  the  secrets  of  success  in  treating 
this  class  of  ruptured  urethras  consists  in  the  careful  estabHshing 
of  free  drainage  by  means  of  the  introduction  of  tubes  through 
multiple  incisions  into  the  infiltrated  portions  of  the  tissues. 

Rupture  of  the  urethra  from  injury  may  be  complete  or  incom- 
plete. If  incomplete,  as  shown  by  the  patient's  ability  to  urinate 
and  painful  micturition,  or  pain  in  the  perineum  with  hematuria 
is  all  that  is  complained  of,  nothing  should  be  done  but  to  keep 
the  patient  under  close  observation.  Not  even  a  urethral  instru- 
ment should  be  passed.  If  slight  perineal  swelling  takes  place 
but  does  not  increase,  it  may  eventually  be  incised  and  clots  let 
out.  If  well-marked  increasing  infiltration  appears,  it  should 
be  incised,  the  urethral  opening,  if  possible,  found,  and  a  retention 
catheter  placed  in  the  bladder  for  a  few  days.  Complete  rupture 
is  indicated  by  the  appearance  of  infiltration,  inability  to  urinate, 
and  probably  severe  shock.  In  such  cases  it  is  necessary  to  oper- 
ate; find  the  distal  end  of  the  urethra,  and  unite  the  two  ends 
over  a  retention  catheter.  In  uniting  the  two  ends  of  the  urethra, 
where  complete  severance  of  the  canal  has  taken  place,  it  should 
be  borne  in  mind  that  as  few  stitches  as  possible  should  be  passed 
through  the  mucous  surface  of  the  urethra.  It  will  be  necessary 
to  pass  two  sutures  to  the  right  and  left  of  the  median  line  through 
the  mucous  surfaces  and  to  tie  them  on  the  same  surfaces.  The 
other   sutures    should   be   passed    through    the   urethra   vdthout 


474  DISEASES    OF   THE    MALE    URETHRA 

invading  the  mucous  surface.  Albarran,  whose  work  in  this 
direction  has  probably  been  more  extensive  than  any  one,  states 
that  he  considers  it  possible  to  get  primary  union  where  the 
urethra  has  been  completely  severed,  and  at  the  same  time  to 
resect  as  much  as  2 J  to  3  cm.  of  the  urethra.  The  method  of 
suturing  mentioned  is  exhibited  in  figures  182-184.  Where 
in  rupture  of  the  urethra  the  injury  has  been  so  excessive  as  to 
destroy  a  larger  amount  of  the  urethra,  necessitating  resection 
of  more  than  25  to  3  cm.,  if  the  two  ends  of  the  urethra  can  be 
brought  into  the  perineal  wound  and  the  roofs  of  the  urethra 
attached  as  near  as  possible  to  one  another,  union  may  be  eventu- 
ally hoped  to  take  place  along  the  roof,  and  the  perineal  fistula 
which  remains  may  afterward  be  cured  by  plastic  operation  as 
described  in  the  article  on  Urethral  Fistula.  In  other  words,  a 
two-step  operation  may  be  performed.  It  may  be  difficult  to  find 
the  distal  end  of  the  urethra;  but,  the  proximal  end  being  found, 
the  distal  end  may  be  searched  for  in  the  tissues  ordinarily  through 
a  longitudinal  perineal  incision.  A  drop  of  blood  or  a  drop  of 
urine  may  indicate  its  presence.  When  not  found  by  longitudi- 
nal perineal  incision,  it  may  be  necessary  to  find  it  by  exposing 
the  prostatic  urethra  through  the  curved  perineal  incision  or  some 
modification  of  it,  as  when  operating  for  a  prostatic  abscess. 
Severe  stricture  is  likely  to  result  and  a  guarded  prognosis  should 
be  given  in  such  a  case. 

ABSCESS  OF  COWPER'S  GLANDS 

These  two  glands,  lying  outside  the  urethra  at  each  side  of  the 
bulb,  occasionally,  but  rarely,  suppurate.  When  they  do,  a  one- 
sided swelling  develops  in  the  perineum  in  the  immediate  vicin- 
ity of  the  bulb,  manifesting  a  tendency  to  extend  backward 
toward  the  anus.  Unless  both  glands  are  involved,  a  general 
brawny  swelling  of  the  perineum  does  not  occur.  It  is  commonly 
believed,  at  the  present  time,  that  abscess  of  Cowper's  glands  is 
almost  invariably  of  tubercular  origin,  which  infection  may  be, 
and  in  such  cases  generally  is,  associated  with  urethritis.  If  these 
cases  are  not  seen  until  some  time  has  elapsed,  they  resemble 
the  urinary  infiltrations  that  occur  as  the  result  of  rupture  of  the 
urethra.     They  are  also  at  times  easily  confused  with  the  efifects 


ABSCESS    OF    COWPER'S   GLANDS 


475 


of  injury  or  with  a  simple  peri-urethral  abscess.  We  have  oper- 
ated on  one  case  in  which  no  sweUing  of  the  perineum  could  be 
made  out,  the  main  indication  being  the  pain  in  the  perineum 
suffered  by  the  patient,  which  was,  of  course,  immediately  re- 
heved  by  the  evacuation  of  the  pus. 


Fig.  igo. — Line  of  incision  for  abscess  containing  extravasated  urine. 


Fig.  igi. — Line  of  incision  for  abscess  of  Cowper's  gland. 


Treatment  consists  of  opening  the  abscesses  at  the  most  promi- 
nent protuberance,  evacuating  the  pus,  and  cleaning  out  the 
cavity  very  thoroughly.  If  the  abscess  is  really  one  of  Cowper's 
gland,  the  hole  in  which  the  finger  is  placed  will  probably  feel 


476 


DISEASES    OF    THE    MALE    URETHRA 


more  circumscribed  than  if  some  other  form  of  abscess  in  that 
locality  is  present.  Urinary  tubercular  fistula  or  extra-urethral 
fistula  may  result,  and  the  case  prove  quite  annoying.  These 
factors  are  to  be  borne  in  mind  in  giving  a  prognosis  before  opera- 
tion. They  are  also  to  be  guarded  against  by  observing  the 
utmost  care  in  cleaning  out  the  cavity.  A  finger  in  the  rectum 
may  be  of  aid  in  indicating  the  point  at  which  the  incision  is  to 
be  made  or  curetage  performed. 


Fig.    192— Circular  suture  of  complete  section  of  the  urethra,  showing  position  of  first 
sutirres  (redrawn  from  Albarran). 


RESECTION  OF  THE  URETHRA 
Resection  of  the  urethra  has  already  been  considered  to  some 
extent  in  connection  with  the  subject  of  complete  rupture  of  the 
urethra.     Resection  of  the  urethra  is  occasionally  performed  for  the 


RESECTION   OP   THE    URETHRA 


477 


relief  of  stricture,  particularly  in  those  cases  in  which  there  is  a 
large  amount  of  cicatricial  tissue  in  and  around  the  floor  of  the 
posterior  urethra.  It  is  rarely  that  resection  is  performed  for  stric- 
ture in  the  anterior  urethra.  Resection  is,  in  the  majority  of  cases, 
a  partial  resection.  The  portion  of  the  urethra  removed  being 
situated  in  the  floor  of  the  urethra,  a  band  of  connecting  mem- 


Fig.    193- — Circular  suture  of  the  complete  section  of  the  urethra,  showing  positions  of 
suture  for  side  and  bottom  walls  (redrawn  from  Albarran). 


brane  is  left  on  the  roof  of  the  urethra.  An  inch  or  more  of  the 
floor  of  the  urethra  may  be  removed  if  the  roof  is  left  intact,  and 
satisfactory  union  yet  take  place.  The  object  to  be  attained  in 
performing  resection  ordinarily  is  to  get  rid  of  old  cicatricial 
masses  and  nodules,  in  the  hope  that  the  scar  that  will  necessarily 
result  from  the  reunion  of  the  severed  portions  will  be  softer  and 


478 


DISEASES    OE   THE    MALE    URETHRA 


more  uniform.  After  resection  of  a  portion  of  the  urethra,  the 
severed  ends  may  be  brought  together;  if  desired,  sHght  longi- 
tudinal incisions  may  be  made  in  the  floor,  so  that  the  resulting 
cicatrix  will  not  be  too  annular  and  the  severed  ends  made  to 
fit  into  each  other  in  triangles.     It  is  more  generally  the  cus- 


Fig.    194. — ^Resection  of  urethra,  where  a  portion  of  the  superior  wall  has  been  left,  showing 
sutures  (redrawn  from  Albarran). 

tom  to  make  the  floor  of  the  perineum  serve  as  the  floor  of  the 
urethra;  one  median  and  an  external  set,  or  the  mattress  form 
of  sutures  which  does  not  include  the  skin,  may  be  employed 
and  the  skin  wound  allowed  to  heal  by  granulation.  To  obtain 
the  best  results  it  is  necessary  to  remove  the  cicatricial  tissue  very 
completely. 


OPERATIONS    FOR   THE    RELIEF    OF   URETHRAL   FISTULA       479 

OPERATIONS  FOR  THE  RELIEF  OF  URETHRAL  FISTULA 
These  operations  may  be  considered  under  three  heads:     (i) 
Operations  for  fistula  in  pendulous  urethra,     (2)  Operation  for 
perineal  urethral  fistula,     (3)  Operation  for  urethral  rectal  fistula. 
Of  these,  the  last  is  the  most  important  variety. 

I.  Urethral  fistula  in  a  pendulous  urethra  may  be  operated  upon 
by  a  method  similar  to  those  pursued  when  the  fistula  is  in  the 
perineum,  or  by  the  methods  recommended  for  the  relief  of  hypo- 
spadias.    If  it  is  deemed  advisable,  a  plastic  operation  may  be 


\J  { 


Fig.  19s. — Urethral  fistula  ;   skin   freed   by 
transverse  incision. 


Fig.   196. — Skin  freed  by  transverse  incis- 
ion and  fistula  closed  by  sutures. 


performed.  The  illustrations  (Figs.  195  to  200)  give  an  idea  of 
the  methods  most  in  vogue.  Diffenbach,  to  avoid  pressure  on  the 
line  of  suture,  makes  two  lateral  incisions,  one  on  each  side  of 
and  one  parallel  to  the  wound,  thus  permitting  the  borders  of 
the  cut  to  unite  without  too  much  strain. 

Several  other  methods  of  operating  for  the  relief  of  this  condi- 
tion have  been  devised.  They  consist  of  the  making  of  various 
forms  of  flaps.  The  persistence  of  erections  increases  the  diffi- 
culty of  uniting  wounds;  and  may  necessitate  a  perineal  incision 
in  order  to  anchor  the  urethra  at  the  fistulous  portion. 


48o 


DISEASES   OF  THE   MALE   URETHRA 


2.  Operations  for  Perineal  Urethral  Fistula. — Resection  of  the 
uretha,  together  with  removal  of  any  cicatricial  tissue  remaining 
in  the  perineum,  is  a  method  that  may  be  employed  for  the  relief 
of  perineal  urethral  fistula.  Resection  of  the  urethra  may  be 
performed  in  the  same  manner  as  is  done  for  the  relief  of  stric- 
ture. Another  method  of  operating  for  perineal  urethral  fistula 
is  to  place  a  guide  in  the  bladder,  incise  the  fistulous  portion  on 
the  guide,  carefully  remove  any  cicatricial  tissue  in  the  region 
of  the  fistula,  sew  up  the  incision  in  the  urethra  with  fine  catgut, 

not  permitting  the  stitches  to  go  through 
the  inner  coat  of  the  urethra,  and  either 
allow  the  patient  to  urinate  naturally 
or  permit  a  retention  catheter  to  remain 


Fig.  197. — Urethral  fistula; 
edges  freshened  and  fistula  cov- 
ered by  scrotal  flap. 


Fig.  iq8. — Repair  of  urethral  fistula  ;  edges  fresh- 
ened, side  incisions  to  overcome  retraction  of  skin. 
Sutures  placed  but  not  tied  (Berger  and  Hartmann). 


in  the  bladder  for  a  few  days.  Another  set  of  stitches  is  taken, 
as  desired,  through  the  exterior  perineal  tissue.  This  is  the  sim- 
plest method  of  operating  for  the  relief  of  these  fistulas. 

In  the  writers'  experience,  however,  this  operation  has  not  been 
so  satisfactory  as  could  be  desired.  They  have  seen  these  fistulas 
most  often  in  hospital  patients,  and  particularly  in  tuberculous 
subjects.  Such  patients  have  poor  reactive  powers  and  do  not 
retain  retention  catheters  well,  as  their  mucous  membranes  are  very 
easily  irritated.    The  most  practicable  method,  the  writers  believe, 


OPERATIONS   FOR   RELIEF    OF    URETHRAL    FISTULA 


481 


Fig.  199. — Urethral 
fistula;  edges  freshened, 
side  incisions,  sutures 
tied  (Berger  and  Hart- 
mann). 


of  Operating  on  a  perineal  urethral  fistula,  as  it  ordinarily  presents 

itself,  was  devised  by  Dr.  Fraser,  of  Brooklyn, 

an  associate  of  Dr.  Henry  H.  Morton,  of   the 

same  city,   to  whom  we  are  indebted  for  the 

suggestion.     The  procedure  consists  in  clearing 

away  the  cicatricial  tissue  surrounding  the  fis- 
tula, introducing  a  sound  into  the  bladder,  and 

then,  a  retention  catheter  having  been  placed  in 

position,  sewing  up  the  perineal  tissues  with  deep 

silver  wire  sutures  which  reach  to,  but  do  not 

go  through,  the  urethra.     These  sutures  are  al- 
lowed to  remain  in  position  for  a  week  or  ten 

days,  and  are  useful  for  holding  freshened  edges 

of  the  perineal  tissue  together  so  that  complete 

union,  to  a  very  great  extent,  may  take  place; 

the  slight  oozing  remaining  after  the  removal 

of  the  sutures  generally  disappears  in  a  few 

days.     If  a  plastic  operation  seems  required  on  one  side  of  the 

urethra,  have  a  quadrilateral  flap  resected  in  such  a  manner  that 
by  turning  it  over  its  cutaneous  face  becomes 
internal,  constituting  the  inner  wall  of  the  fu- 
ture canal.  A  second  flap  with  its  base  external 
is  cut  from  another  lip  of  the  canal  and  made  to 
recover  the  cutaneous  surface  of  the  first  turned 
over  flap,  and  the  borders  of  this  flap  are  fas- 
tened in  such  manner  as  to  cover  the  bleeding 
surface  created  by  turning  back  the  first  flap. 
If  a  small  fistula  remains  following  this,  it  may 
later  on  be  cured  by  freshening  its  edges. 

3.  Operations  for  the  Relief  of  Urethro- 
rectal Fistulas.— These  fistulas  have,  until 
recently,  been  rarely  reported.  Ordinarily,  they 
are  due  to  injury  from  within  the  urethra, 
owing  to  improper  instrumentation,  or  they 
may  be  due  to  accident  from  without.  In  a 
case  recently  under  the  writers'  care,  it  was 
caused  by  injuries  sustained  during  an  explosion 

of  dynamite.     Within  the  last  few  years, — i.  e.,  since  operations 
31 


Fig.  200.  —  Ureth- 
ral fistula ;  liberation 
of  skin  by  the  aid  of 
two  transverse  in- 
cisions, method  of 
Nelaton  (Berger  and 
Hartmann). 


482 


DISEASES   OF   THE    MALE    URETHRA 


through  the  perineal  roof  for  the  reHef  of  prostatic  hypertrophy 
have  become  so  common, — urethrorectal  fistulas  have  increased 
largely  in  number  mostly  following  this  operation. 

Diagnosis. — This  is  easily  made  from  the  fact  that,  generally, 
a  portion  of  the  urine  is  voided  through  the  rectum,  flatus  and 
occasionally  liquid  feces  being  passed  through  the  penis.  With 
a  sound  in  the  bladder  and  a  finger  in  the  rectum,  the  latter  may 
be  pressed  on  the  surface  of  the  sound,  which  presents  itself  with- 


Fig.  20I. — First  step  of  Tuttle's  operation  for  repair  of  recto-urethral  fistula. 


out  offering  any  impediment  to  the  finger,  and  the  size  of  the 
fistulous  opening  may  thus  be  made  out. 

Prognosis. — If,  immediately  after  an  injury,  the  fistulous  open- 
ing in  the  rectum  is  found  to  be  no  larger  than  a  ten-cent  piece  or 
a  copper  cent,  the  prognosis  is  good,  complete  recovery  ordinarily 
following  the  adoption  of  simple  measures.  If  the  urethrorectal 
opening  is  large,  the  prognosis  is  doubtful. 

Treatment. — There  are  three  methods  of  treatment:  palliative, 
local,  and  operative.  The  palliative  treatment  consists  in  the 
patient  using  the  greatest  care  in  regard  to  his  diet,  guarding 
against  constipation,  and,  above  all,  against  diarrhea. 


OPERATIONS   FOR   RELIEF    OF    URETHRAL    FISTULA 


483 


He  must  also  observe  the  utmost  cleanliness  of  that  portion 
of  the  rectum  that  may  extend  from  the  anus  to  the  fistulous 
rectal  opening.  The  best  means  of  securing  this  is  by  ordering 
rectal  injections  of  some  mild  cleansing  wash,  such  as  a  weak 
solution  of  some  mild  antiseptic. 

Local  measures  consist  in  the  introduction  of  a  Kollmann 
dilator  into  the  bladder  through  the  urethra  at  the  meatus  at 
intervals  of  four  or  five  days,  and  the  gradual  overdistention  of 


:i  ••?•■'•■'; :'  •.^^.V-'.-'T-';- 


Fig.  202. — ^Second  step  of  Tuttle's  operation  for  repair  of  recto-urethral  fistula. 

the  prostatic  and  membranous  urethra.  If  possible,  the  dilata- 
tion should  be  continued  until  a  caliber  equaling  that  of  No.  45  F. 
has  been  reached.  If  a  Kollmann  dilator  is  not  available  for 
this  purpose,  steel  sounds  may  be  used.  In  passing  either  the 
sound  or  the  dilator,  however,  great  care  must  be  observed  to  see 
that  the  beak  of  the  instrument  does  not  enter  the  rectal  opening 
through  the  urethra  instead  of  entering  the  bladder.  The  patient 
himself  will  generally  be  aware  of  it  when  this  occurs.  To  obviate 
this  it  is  best  to  proceed  slowly,  to  hug  the  roof  of  the  urethra 
closely,  and,  while  passing  the  instrument,  to  insert  a  forefinger 
into  the  rectum  in  order  to  learn  when  the  beak  of  the  instrument 


484 


DISEASES   OF   THE    MALE    URETHRA 


enters  this,  and  to  help  to  guide  it  upward  and  outward  on  its  way 
to  the  bladder.  Such  remedial  measures  as  cauterizing  the  edges 
of  the  fistula,  either  in  the  rectum  or  the  perineum,  have  proved 
useless  in  the  writers'  hands. 

Operative  Treatment. — Although  a  number  of  operations  have 
been  devised  for  the  reUef  of  this  condition,  one  that,  in  the  writers' 
experience,  has  been  followed  by  good  results,  is  that  of  Dr.  James 
P.  Tuttle,  of  New  York  city.     This  is  performed  as  follows : 


Fig.  203. — Third  step  of  Tuttle's  operation  for  repair  of  recto-urethral  fistula. 

Tuttle's   Operation   for   Closure   of    Recto-urethral    Fistula. — 

First :  The  operation  should  not  be  undertaken  until  suppuration 
in  the  bladder,  the  urethra,  and  the  fistulous  tract  has  completely 
disappeared. 

Second:  All  strictures  of  the  pendulous  urethra  should  first  be 
thoroughly  dilated.  ' 

Third:  The  operation  should  be  preceded  by  a  week's  course 
of  urotropin  and  intestinal  antiseptics. 

The  Operation. — With  the  patient  in  the  Sims  posture,  the  hips 
being  well  elevated,  the  urethra  is  laid  open  from  the  scrotum 
back  to  the  fistula;   the  incision  is  then  carried  through  into  the 


OPERATIONS   FOR   RELIEF    OF    URETHRAL   FISTULA 


485 


rectum,  thus  making  an  opening  that  reaches  to  the  fistula.  The 
latter  is  then  dissected  up  from  the  rectal  side  and  left  attached 
to  the  urethra.  The  rectum  and  urethra  are  next  separated 
transversely  well  above  the  fistula,  so  that  the  anterior  rectal 
wall  can  be  dragged  down  over  the  fistula  to  the  anal  margin. 
The  mucous  membrane  is  then  dissected  from  the  anal  margin 
on  each  side  of  the  wound  and  trimmed  off,  so  as  to  form  a  crescent 
with  the  edge  of  the  gut  that  has  been  separated  from  the  urethra 
above  the  fistula.  A  soft  rubber  No.  22  F.  catheter  is  now  passed 
from  the  meatus  into  the  bladder.     The  edges  of  the  fistula  are 


Fig.  204.— Fourth  step  of  Tuttle's  operation  for  repair  of  recto-urethral  fistula. 

then  inverted,  and  their  freshened  surfaces  sutured  together 
with  No.  I  ten-day  chromicized  gut,  the  continuous  Lembert 
suture  being  employed.  The  urethra  is  thus  closed  down  to 
one  half  inch  below  the  level  of  the  external  sphincter  ani.  The 
remainder  of  the  perineal  wound  and  urethra  are  left  open.  Rein- 
forcing flaps  are  then  cut  from  the  perineal  tissues  on  each  side  of 
the  sutured  area,  and  brought  together  over  the  first  line  of 
sutures  by  a  continuous  chromicized  suture.  A  silkworm-gut 
suture  is  then  passed  through  the  skin  from  one  side  of  the  anus 
up  through  the  perineal  tissues  to  the  apex  of  the  wound,  through 


.86  DISEASES   OF    THE    MALE    URETHRA 

the  muscular  wall  of  the  gut  at  this  point,  and  back  through  the 
perineal  tissues  and  skin  on  the  opposite  side,  the  ends  being  left 
untied.  The  anterior  wall  of  the  rectum  is  then  brought  down 
and  sutured  to  the  margin  of  the  anus,  from  which  the  mucous 
membrane  was  dissected,  thus  forming  an  impervious  layer  be- 
tween the  sutured  urethra  and  the  rectal  canal.  Finally,  the 
silkworm-gut  suture,  which  acts  as  an  anchor  to  the  rectal  wall, 
dragging  it  down  and  preventing  tension  on  the  marginal  sutures, 
is  tied  firmly  over  a  small  roll  of  gauze,  so  that  it  will  not  cut  into 
the  skin.  The  perineal  wound  is  then  packed,  and  the  catheter 
fastened  at  the  meatus,  so  that  it  cannot  slip  out.  The  catheter 
is  left  in  situ  ten  days  or  more.  When  it  is  taken  out,  a  perineal 
fistula  remains  that  usually  heals  in  about  three  weeks. 


CHAPTER  XXIII 

THE  FEMALE  URETHRA 

ANATOMY 

The  female  urethra  is  considerably  shorter  than  that  of  the 
male  and  it  virtually  represents  but  the  posterior  portion  of  the 
male  passage.  It  is  about  one  and  one-half  inches  in  length,  but 
varies  considerably  in  this  respect  in  different  subjects.  Its  walls 
are  ordinarily  in  immediate  apposition,  but  when  its  longitudinal 
corrugations  are  distended  the  passage  is  about  one-fourth  inch 
in  diameter.  The  tube  can  be  greatly  dilated,  however,  sufH- 
ciently  so  as  to  permit  the  introduction  of  a  palpating  finger. 

The  organ  lies  embedded  in  the  anterior  vaginal  wall  and  its 
external  orifice  is  found  about  one  inch  posterior  to  the  glans 
clitoris.  It  passes  upward  and  backward,  joining  with  the  walls 
of  the  bladder  and  draining  this  cavity  at  its  most  pendent  por- 
tion, the  trigone.  The  internal  or  cystic  orifice  is  stellate  in  the 
resting  condition  and  the  external  orifice  or  meatus  presents  itself 
between  the  nymphae  as  a  vertical  sHt  with  slightly  raised  margins. 
The  urethra  penetrates  the  triangular  ligament  and  is  attached 
to  the  pubic  arch  by  the  pubovesical  ligaments.  The  body  of 
the  tube  is  inclosed  by  the  compressor  urethrae  muscle.  The 
ducts  of  Skene  enter  the  urethra  just  within  the  meatus.  These 
gland  tubules  are  of  considerable  importance,  since  in  infectious 
diseases  of  the  female  urethra  they  afford  lodgment  for  micro- 
organisms which  may  later  infect  the  bodies  of  the  glands  and 
excite  a  persistent  inflammatory  disease  with  sporadic  outbreaks 
of  adjacent  infection. 

The  walls  of  the  urethra  are  made  up,  beginning  from  within, 
of  a  thick  layer  of  transitional  epithehum,  continuous  with  that 
lining  the  bladder  and  like  it  in  its  appearance;  at  the  external 
meatus  this  epithelium  becomes  transformed  into  a  form  like 
that   making   up   the   external   genital  mucosa.     At  the  vesical 

487 


488  THE    FEMALE    URETHRA 

extremity  of  the  channel  many  mucous  glands  are  found,  the  ducts 
of  which  enter  the  urethra  at  this  point.  The  mucous  membrane 
of  the  urethra  is  laid  down  on  a  delicate  basement  membrane 
which  is  in  turn  applied  to  a  thick  and  very  highly  vascular  con- 
nective-tissue coat  which  is  further  characterized  by  the  presence 
of  many  elastic  connective-tissue  fibrils.  The  connective-tissue 
layer  is  inclosed  by  an  inner  longitudinal  and  an  outer  circular 
layer  of  smooth  involuntary  muscle  which  acts  as  and  receives 
the  name  of  the  compressor  urethrge  muscle.  The  muscular  coat 
is  united  to  the  surrounding  structures  by  a  layer  of  connective 
tissue  which  blends  with  the  surrounding  stroma. 

The  lymphatics  of  the  upper  portion  of  the  urethra  drain  into 
the  internal  iUac  nodes,  but  the  lower  ones  enter  into  the  channels 
of  the  external  genitals  and  so  pass  to  the  inguinal  nodes.  The 
blood-vessels  and  nerves  are  very  abundant  and  are  derived  from 
the  same  sources  as  those  supplied  to  the  vagina. 

CONGENITAL  MALFORMATIONS 
Congenital  malformations  of  the  female  urethra  are  more  rare 
than  in  the  male.  They  are  usually  found  associated  with  accom- 
panying malformations  of  the  genitals.  Atresia  is  the  most  fre- 
quent congenital  malformation  with  which  the  obstetrician  and 
general  practitioner  meets.  Its  treatment  is  obvious  and  the 
severity  of  measures  necessary  depends  on  the  degree  of  the 
atresia.  Occasionally  the  urethral  meatus  is  indicated  and  the 
septum  separating  it  from  the  bladder  can  be  perforated  by  a  probe 
or  sound.  When  no  such  landmarks  exist  and  where  the  tube 
cannot  be  felt,  it  may  be  necessary  to  open  the  bladder  suprapu- 
bically  or  through  the  vagina,  following  later  with  a  reparative 
or  constructive  plastic  operation  such  as  is  indicated  by  the  asso- 
ciated lesions  of  the  particular  case  under  question.  Hypospa- 
dias and  epispadias  are  very  rare  and  exstrophy  of  the  bladder  is 
also  less  frequent  than  in  the  male.  The  treatment  of  these  con- 
ditions has  been  sufficiently  discussed  under  the  like  conditions 
in  the  male. 

Traumatisms  of  the  urethra  are  much  less  common  in  the 
female  than  in  the  male  on  account  of  the  protected  location  of 
the  canal.     As  a  rule,  they  result  from  direct  violence,  and  the 


EXAMINATION   OF   THE   FEMALE    URETHRA  489 

chief  difficulties  presented  in  their  treatment  fohow  from  their 
close  proximity  to  the  genital  tract  and  the  rectum,  from  which 
infections  are  likely  to  arise. 

Treatment  is  directed  mainly  toward  surgical  repair,  when  neces- 
sary, and  toward  the  prevention  of  septic  infection.  On  account 
of  the  great  vascularity  healing  generally  takes  place  rapidly. 

EXAMINATION  OF  THE  FEMALE  URETHRA 
On  account  of  the  short  length  of  the  channel,  its  dilatability, 
and  its  accessible  position,  examination  of  the  female  urethra  is  a 
much  more  simple  matter  than  that  of  the  male.  Palpation  of 
practically  the  entire  length  of  the  passage  can  be  usually  satis- 
factorily performed  through  the  anterior  vaginal  wall,  the  index 
or  examining  finger  being  introduced  for  that  purpose  into  the 
vagina.  In  this  manner,  calcuh  lodged  in  the  lumen  may  be  read- 
ily detected,  and  in  most  cases  the  location  and  extent  of  stric- 
tures or  new-growth  formations  can  be  ascertained. 

Examination  of  the  mucous  membrane  can  be  best  accomplished 
by  the  introduction  of  a  srtiall  sized  Kelly  cystoscope,  and  as  the 
instrument  is  slowly  withdrawn  the  walls  of  the  canal  fall  together 
over  the  open  end  of  the  instrument,  when  they  can  be  closely 
inspected  bit  by  bit  as  the  tube  is  slowly  withdrawn.  A  strong 
light  is  necessary  and  the  best  results  are  obtained  when  light 
reflected  by  means  of  a  head  mirror  is  employed.  Where  Kelly's 
instrument  is  not  available  examination  can  be  quite  satisfactorily 
accomplished  with  an  ordinary  urethral  endoscope  of  large  size. 
In  the  withdrawal  of  the  tube  one  must  particularly  inspect  the 
openings  of  the  gland  tubules,  which  appear  normally  as  minute, 
yellowish,  sHghtly  pink  spots.  Inflammatory  and  ulcerative 
processes  are  especially  apt  to  be  seen  at  these  points.  The 
entrance  of  the  ducts  of  Skene's  glands  appears  just  as  the  instru- 
ment is  about  to  escape  from  the  urethra.  Where  infection  of 
these  glands  is  suspected,  massage  along  their  course  may  force  a 
droplet  of  discharge  into  the  urethra,  from  which  it  may  be 
collected  for  examination  by  means  of  an  applicator.  Abso- 
lute asepsis  is,  of  course,  requisite  in  every  step  of  the  examina- 
tion. 


490  THE   FEMALE    URETHRA 

STRICTURE  OF  THE  FEMALE  URETHRA 

Strictures  of  the  female  urethra  are  rare  as  compared  to  the 
like  change  in  the  male  canal,  still  they  are  present  much  more 
commonly  than  is  generally  thought  to  be  the  case.  A  stricture 
of  considerable  degree  may  exist  without  attracting  the  especial 
attention  of  the  casual  observer,  since  unless  it  be  very  marked 
or  accompanied  by  acute  inflammatory  changes,  the  s}Tnptoms 
complained  of  are  few  and  considerable  retention  of  residual  urine 
may  sometimes  exist  for  a  long  time  in  women  without  attracting 
the  attention  of  the  patient. 

Strictures  most  commonly  follow  previous  inflammatory  disease 
of  the  urethra,  in  the  cause  of  which,  as  in  the  male,  gonorrhea 
leads  in  frequency.  Tubercular  or  syphilitic  ulcerations  are,  how- 
ever, by  no  means  unknown,  and  strictures  following  traumatism 
in  child-birth  are  relatively  common.  They  are  very  apt  to  occur 
with  new-growths  of  the  urethra  or  in  the  course  of  neoplasms  of 
adjacent  parts,  also  from  inflammatory  or  ulcerative  disease  of 
the  vagina  or  vulva. 

Diagnosis. — Diagnosis  is  usually  readily  effected,  by  digital 
examination  through  the  vagina,  when  a  thickened  node  of  infil- 
tration or  fibrosis  may  be  detected;  quite  frequently  it  is  first 
discovered  through  attempting  to  pass  a  catheter.  The  use  of 
the  ordinar}"  male  sound  is  not  satisfactory  for  the  detection  of 
the  stricture,  for  in  nearly  all  cases  the  lumen  can  be  so  readily 
dilated  as  to  permit  the  passage  of  such  an  instrument.  The 
olive-tipped  sound  should  be  used,  and  unless  very  slight  the 
passage  of  a  stricture  by  one  of  these  instruments  can  be  very 
easily  detected  by  the  practised  hand. 

Treatment. — Treatment  follows  along  the  same  lines  as  employed 
in  the  male.  The  most  efficient  is  the  use  of  graduated  sounds  or 
bougies.  Dilation  can  be  well  effected  under  cocain  anesthesia, 
or  in  less  marked  cases  without  any  anesthetic  whatever.  Rapid 
dilation  must  not  be  practised,  and  of  course  rigid  asepsis  is  to 
guard  every  step.  Where  extensive  ulceration,  as  in  new-growths 
of  the  parts,  or  where  a  large  amount  of  cicatricial  tissue  causes 
a  stricture  near  the  external  meatus,  it  may  be  found  better  to 
form    an    artificial   meatus   in   the    anterior   vaginal    wall.     The 


DILATION    OF   THE    URETHRA  49 1 

portion  of  the  tube  posterior  to  the  stricture  should  be  brought 
down  into  a  vaginal  incision  and  its  mucosa  stitched  to  that 
of  the  vagina.  A  catheter  must  be  left  in  position  until  union 
has  takeh  place. 

These  strictures  sometimes  show  a  marked  tendency  to  recur, 
and  it  is  frequently  necessary  to  redilate  from  time  to  time. 
In  every  case  injury  to  the  tissues  must  be  carefully  avoided  or 
inflammation  and  subsequent  formation  of  more  cicatricial  tissue 
may  follow. 

DILATION  OF  THE  URETHRA 

Relaxed  or  patulous  urethra  is  not  uncommonly  seen  in  women. 
As  a  rule,  incontinence  of  urine  does  not  follow,  but  in  some  cases 
the  relaxation  may  be  so  marked  as  to  prevent  normal  retention 
and  operative  relief  may  be  imperative.  In  some  cases  prolapse 
of  the  mucous  membrane  may  take  place  and  a  condition  simulat- 
ing hemorrhoids  in  a  small  way  may  appear. 

Dilation  of  the  urethra  most  commonly  follows  overstretching 
of  the  tube,  perhaps  in  unskilful  endoscopy,  in  the  extraction 
of  a  cystic  calculus  or  occasionally  where  the  entire  tissues  of  the 
parts  are  relaxed  as  a  result  of  some  general  or  local  disease.  Dila- 
tion of  the  urethra,  often  to  great  size,  is  occasionally  seen  in  cases 
where,  owing  to  malformation  or  agenesis  of  the  vagina  or  exter- 
nal genitals,  persistent  attempts  have  finally  dilated  the  urethra 
up  so  that  coitus  through  this  channel  is  possible.  The  authors 
have  seen  two  such  cases;  in  neither,  however,  did  the  patient 
experience  any  resulting  difficulty,  nor  were  they  aw^are  of  any- 
thing abnormal  in  their  condition.  Kelly  states  that,  as  a  rule, 
these  cases  do  not  complain  of  incontinence,  and  he  advises  let- 
ting the  condition  alone  except  where  the  normal  genital  channel 
can  be  established,  when  the  urethra  commonly  contracts  down 
considerably. 

Treatment. — As  just  mentioned,  certain  cases  demand  no  treat- 
ment. Where  prolapse  of  the  mucosa  has  taken  place,  the  pro- 
tuberant tissues  are  to  be  cut  away  and  the  edges  of  the  wound 
carefully  sutured  to  the  normal  mucosa.  Where  the  condition 
is  due  to  relaxation  of  the  surrounding  parts  or  to  traumatism, 
interference  may  be  necessary  and  the  surplus  tissue  may  be 
removed  surgically,     A  properly  fitted  hard-rubber  or  glass  vagi- 


492  THE   FEMALE    URETHRA 

nal  pessary  may  in  some  cases  sufficiently  replace  the  tissues  so 
that  operative  procedure  may  be  obviated  or  at  least  delayed. 

URETHRAL  FISSURE  ' 

This  is  a  condition  of  rather  frequent  occurrence.  It  consists  in 
a  fissure  or  crack  in  the  mucous  membrane  which  usually  extends 
longitudinally  to  the  lumen.  It  may  be  caused  by  rapid  dilation, 
or  more  frequently  it  follows  mild  or  catarrhal  types  of  urethritis. 
The  condition  is  often  very  painful  and  may  cause  considerable 
irritation.  It  is  readily  detected  from  the  history  and  on  exami- 
nation of  the  urethra.  It  may  be  treated  by  the  application  of 
silver  nitrate  in  from  3  to  7  per  cent,  strength;  in  certain  aggra- 
vated cases  careful  dilation  of  the  urethra  must  precede  the 
treatment.  Occasionally  we  have  found  it  necessary  to  repeat 
the  treatment  for  a  considerable  time  before  complete  relief  was 
afforded.  As  a  general  thing  these  fissures  are  associated  with 
more  or  less  urethritis  and  sometimes  with  cystitis. 

PERI-URETHRAL  ABSCESS 
Abscess  formation  occasionally  occurs  about  the  female  urethra. 
As  a  rule,  it  follows  urethritis  with  infection  of  the  urethral  glands, 
and  it  is  commonly  gonorrheal  in  origin.  Sometimes  these  ab- 
scesses occur  as  a  result  of  tubercular  or  syphilitic  ulcerations 
of  the  urethra.  They  may  point  into  the  urethra,  or  may  appear 
as  a  bulging  sac  on  the  anterior  wall  of  the  vagina.  Their  treat- 
ment is  naturally  incision  and  drainage. 

URETHRITIS 

Urethritis  is  probably  as  frequent  in  the  female  as  in  the  male, 
but  in  most  cases  its  course  is  so  mild  that  it  appears  but  as  an 
incident  in  the  course  of  a  vaginitis  or  vulvitis,  and  often  escapes 
the  observation  of  the  physician.  It  is  caused  most  commonly 
by  the  gonococcus,  but  may  follow  infection  with  any  of  the  va- 
rious infectious  agents  or  it  may  result  from  traumatism.  In 
the  last  mentioned  cases,  unless  complicated  by  subsequent  in- 
fection or  by  stricture,  the  progress  is  toward  recovery  and  the 
course  of  the  disease  is  short. 

Some  cases  of  urethritis,  especially  some  cases  of  gonorrheal 


URETHRITIS  493 

infection,  are  very  resistant  to  treatment  and  are  often  most 
distressing  to  the  patient.  The  appearance  of  the  mucous  mem- 
brane varies  from  bright  pink  to  deep  purple  in  color.  Eversion 
and  swelling  of  the  mucosa  at  the  meatus  may  be  seen  and  an 
abundant  discharge  is  usually  present.  Where  infection  of  the 
ducts  of  Skene's  glands  is,  as  is  most  commonly  the  case,  present 
pus  can  be  expressed  from  them  by  massage  through  the  vagina. 
Microscopic  examination  of  the  exudate  is  always  advisable  in 
these  cases  in  order  that  the  definite  etiologic  agents  may  be 
demonstrated. 

Ulceration  of  the  urethra  is  very  prone  to  occur  in  acute  ure- 
thritis, and,  as  in  the  male,  stricture  is  apt  to  take  place  with  heal- 
ing of  the  ulcer. 

In  chronic  urethritis,  as  a  rule,  the  entire  surface  of  the  mem- 
brane is  not  involved  and  the  parts  are  not  so  tender  but  that 
the}^  may  be  satisfactorily  examined  and  treated  through  the 
endoscope.  Patches  of  redness,  of  superficial  ulceration,  or  of 
edema  are  seen  and  direct  applications  to  the  diseased  surface 
are  often  possible. 

Treatment. — The  treatment  in  general  follows  closely  along 
the  lines  outlined  for  the  treatment  of  the  Hke  condition  in  the 
male;  the  disease  as  a  general  thing,  however,  responds  much 
more  readily  to  treatment.  In  many  cases,  owing  to  the  short- 
ness of  the  canal  and  the  less  complicated  nature  of  the  mucous 
membrane,  the  disease  is  self-limited.  Many  cases  take  place  and 
become  cured  without  even  the  knowledge  of  the  physician  or 
particular  complaint  on  the  part  of  the  patient.  This  is  especi- 
ally frequent  when  the  adjacent  parts  are  the  seat  of  a  more 
active  inflammatory  process,  as  in  gonorrheal  vaginitis  and  vul- 
vitis. 

One  of  the  first  steps  in  the  treatment  is  the  rendering  of  the 
urine  bland  by  the  use  of  large  amounts  of  water  and  perhaps 
by  administering  alkalis.  Beyond  question  a  certain  number  of 
cases  are  set  up  by  an  intensely  acid  urine.  Warm  sitz-baths 
are  often  of  great  benefit,  not  only  in  the  cure  of  the  disease  but 
also  in  reHef  of  its  most  annoying  symptoms.  Where  severe  pain 
occurs  on  passing  the  urine,  it  may  often  be  voided  with  com- 
paratively little  distress  while  in  the  warm  bath.     Local  applica- 


494  '•'HE   FEMALE   URETHRA  ♦ 

tions  of  various  sedative  and  astringent  lotions  to  the  external 
meatus  are  often  beneficial,  and  of  such  the  familiar  "lead  and 
opium  wash"  is  one  of  the  best. 

As  a  rule,  we  have  not  found  local  irrigation  of  the  membrane 
advantageous  in  acute  cases.  Irrigation  in  this  stage  of  the 
disease  is  very  apt  to  cause  infection  of  the  bladder  and  cystitis. 
General  measures  suffice  in  most  cases  at  least  until  the  exquisite 
tenderness  has  subsided,  when  direct  applications  of  silver  nitrate 
in  a  strength  varvingfrom  3  to  10  per  cent,  may  be  made  to  the 
mucous  membrane.  Protargol  or  argyrol  act  better  in  the  more 
acute  cases,  especially  where  marked  edema  is  present.  In  some 
patients  where  the  inflammation  has  extended  from  the  urethra 
into  the  bladder,  where  it  is  frequently  located  just  at  the  tri- 
gone or  about  the  urethral  orifice,  it  is  good  practice  to  first  irri- 
gate the  urethra  with  a  mild  solution  of  potassium  permanganate, 
protargol,  or  silver  nitrate,  and  then  to  inject  a  small  quantity 
into  the  bladder,  where  the  patient  should  retain  the  fluid  for 
a  few  moments  before  it  is  voided. 

Chronic  cases  are  to  be  treated  very  much  along  the  same  lines, 
but  here,  as  a  general  thing,  direct  applications  to  the  diseased 
portions  of  the  mucous  membrane  are  possible  through  the  endo- 
scope and  stronger  solutions  are  necessary. 

Throughout  the  entire  treatment  of  both  acute  and  chronic 
urethritis  attention  must  be  paid  to  the  general  condition  of  the 
patient  and  the  administration  of  tonics  and  a  properly  adjusted 
diet  are  often  essential  for  rapid  recovery. 

TUMORS  OF  THE  FEMALE  URETHRA 
Tumors  of  the  female  urethra  are  not  common  except  where 
secondary  invasion  of  the  urethra  has  taken  place  from  neo- 
plasms of  the  vulva,  vagina,  or  uterus.  Primary  neoplasms  appear 
most  commonly  about  the  external  meatus,  where  diagnosis  is 
easy,  and  as  a  rule  the  nature  of  the  growth  is  sufficiently  evident 
on  mere  gross  inspection,  though  postoperative  microscopic  ex- 
amination is  necessary  for  certainty  and  for  proper  postoperative 
treatment.  The  tumors  are  conveniently  divided  for  discussion 
into  malignant  and  innocent. 

Malignant  Tumors. — Carcinoma  is  the  most  frequent  malignant 


TUMORS  OF  THE  FEMALE  URETHRA  495 

tumor  of  the  urethra;  it  is,  however,  rare  as  a  primary  growth. 
It  is  seen  most  often  as  an  epithelioma  of  the  squamous  celled 
type,  originating,  when  primary,  from  the  mucosa  of  the  meatus, 
as  a  rule.  The  malignant  character  of  the  growth  may  be  recog- 
nized by  its  tendency  to  infiltrate,  by  superficial  necrosis,  and  by 
the  pain  which  accompanies  it,  though  the  parts  are  generally 
not  very  sensitive  locally.  As  a  general  thing  the  gross  appear- 
ance of  the  growth  is  such  as  to  leave  little  doubt  as  to  its  nature. 
Carcinoma  of  the  urethra  is  in  our  experience  most  commonly 
confused  with  syphilitic  ulcerations.  Differential  diagnosis  must 
rest  on  the  Wassermaim  reaction  response  to  syphilitic  treatment 
and  on  microscopic  examination. 

Sarcoma  of  the  urethra  is  very  rare  except  in  general  or  local 
sarcomatosis. 

Treatment. — The  treatment  in  maUgnant  tumors  of  the  urethra 
is  early  extirpation  in  all  cases  whenever  this  is  possible.  The 
incision  should  include  as  much  of  the  surrounding  tissues  as 
practicable,  and  we  strongly  advise  the  discrete  application  of  the 
x-iay  after  the  surgical  removal  of  these  growths.  Care  must  be 
taken  in  the  use  of  this  agent,  however,  and  it  should  not  be  em- 
ployed about  these  delicate  mucous  membranes  except  in  the 
hands  of  an  expert. 

Innocent  Tumors. — The  most  frequent  innocent  tumors  of  the 
female  urethra  are  condylomata.  They  appear  as  more  or  less 
pediculated  papillomatous  masses,  generally  in  groups  and  more 
or  less  symmetrically  arranged,  for  they  are  autoinoculable. 
They  probably  bear  a  direct  relationship  to  uncleanHness  and 
in  many  instances  are  the  result  of  venereal  inoculation.  They 
are  ordinarily  painless  except  in  secondary  inflammation;  they 
grow  rapidly,  particularly  under  conditions  of  moisture  and  filth, 
and  may  develop  to  tumors  of  considerable  size.  The  treatment 
consists  in  removal,  and  the  surgeon  should  be  particular  to 
fully  excise  the  base  of  the  growth,  and  the  wound  should  then  be 
cauterized  with  strong  silver  nitrate  solution. 

Urethral  caruncles  are  tumors  developing  from  the  lips  of  the 
external  meatus.  They  are  deep  purple  in  color,  due  to  the  large 
number  of  blood-vessels  which  enter  into  their  structure.  They 
may  be  either  pediculated  or  sessile.     They  are  covered  over  by  a 


496  THE    FEMALE    URETHRA 

delicate  reflection  of  the  mucous  membrane,  bleed  readily,  and 
are  exquisitely  tender.  They  cause  great  distress,  especially  on 
urination  or  from  chafing  or  pressure.  They  may  further  become 
intensely  inflamed.  Microscopically  they  are  made  up  of  a  deli- 
cate connective-tissue  stroma  which  supports  a  very  abundant 
number  of  large,  thin-walled  blood-vessels.  The  tumors  are  prob- 
ably inflammatory  in  origin;  they  do  not  recur  on  removal  and 
never  grow  to  be  of  large  size. 

The  treatment  consists  in  removal,  which  must  be  done  under 
efficient  local  or  general  anesthesia.  In  nearly  all  cases  removal 
by  the  knife  is  to  be  greatly  preferred  to  cauterization,  both  be- 
cause the  pain  during  and  after  the  operation  is  less  and  also 
because  the  resulting  scar  after  excision  is  much  smaller  and  better 
placed  than  when  removed  by  cautery. 

Polypoid  fibroma  are  occasionally  found  -attached  to  the  ure- 
thral lips  or  projecting  from  the  tissues  immediately  internal 
to  the  meatus.  The  mass  of  the  tumors  is  made  up  of  myxo- 
matous or  embryonal  connective  tissue  and  they  are  covered  in 
by  a  reflection  of  the  urethral  mucosa.  Blood-vessels  are  not 
numerous.  The  tumors  may  cause  considerable  obstruction  of 
the  urethra  at  times,  but  unless  they  become  much  inflamed 
they  are  generally  painless.  Treatment  consists  in  removal  by 
cutting  them  away  at  the  pedicle  or  by  twisting  them  off  at  this 
place.     They  do  not  recur. 


CHAPTER  XXIV 


THE  PENIS 

INJURIES  OF  THE  PENIS 
Treatment. — Generally  speaking,  injuries  or  wounds  of  the 
penis  have  a  tendency  to  heal  rapidly.  It  is  not  deemed  neces- 
sary to  enumerate  here  the  various  injuries  or  wounds  of  this  organ 
that  have  been  recorded  from  time  to  time.  The  organ  may  be 
completely  or  incompletely  severed  or  portions  of  it  may  be  torn 
away.  When  completely 
severed,  the  ordinary  sur- 
gical measures  for  arrest- 
ing hemorrhage  should 
be  adopted  and  a  good 
stump  made.  When  in- 
completely severed,  the 
aim  should  be  to  pre- 
serve the  integrity  of  the 
urethra  as  much  as  pos- 
sible by  means  of  deep 
and  superficial  sutures, 
placing  the  organ  on  a 
splint,  and  establishing 
either  perineal  or  supra- 
pubic    drainage     and  ^  r^      .-      ft,      ,u       t    .i,    ,   .• 

^  "^  Fig.  205. — Operation  of  Bessel-Hagen  for  the  plastic 

or1r\T-i+inrr         ciir-Vi  nfVipr  repair  of  denudations  of  skin  of  the  penis  where  a  scro- 

aaopung         bUCll         UUiei  tal  flap  cannot  be  obtained.     First  step,  bridge  is  taken 

,^^^^..-^^r^  nr^  i^riU   r.-4-.TQ  +ViQ  from  theabdominal  wall  and  penis  inserted  through 

measures  as  will  give  the  j^  (redrawn  from  Berger  and  Hartmann). 

injured  organ  a  chance  to 

heal.  An  astonishing  amount  of  the  outside  skin  may  be  torn 
away  and  repair  still  take  place.  If  much  of  the  skin  surrounding 
the  penis  has  been  destroyed,  autoplastic  measures  may  be  at- 
tempted. These  may  be  divided  into  two  classes:  First,  when 
a  large  portion  of  the  skin  has  been  lost  and  scrotal  tissue  can  be 
used,  and,  second,  when  a  large  portion  of  the  skin  has  been  lost 
32  407 


498 


THE    PENIS 


and  scrotal  tissue  cannot  be  used. 


T> 


When  the  skin  on  the  inferior 
surface  of  the  penis,  ex- 
tending to  the  scrotum, 
is  lost,  the  foreskin,  if  in- 
tact, may  be  split,  and  a 
portion  of  this  may  be 
used.  Reich's  method, 
shown  in  fig.  207,  con- 
sists of  making  a  bridge 
from  the  scrotal  tissue. 
Twenty  days  afterward 
the  bridge  is  freed  by 
making  an  incision  on 
each  side.  When  pos- 
sible, the  skin  from  the 
scrotum  is  used. 

Bessel-Hagen'smethod 
is  illustrated  by  figs.  205, 
206.      When    skin    from 
the  scrotum   is   lacking, 
the  penis  is  made  to  pass  under  a  bridge  cut  from  the  belly. 


Fig.  206. — The  second  step  in  the  Bessel-Hagen 
operation.  Eleven  days  after  first  operation  the  line 
a  b  and  a'  b'  is  cut  through  to  recover  the  denuded 
penis.  Then  a  flap  L  is  made  following  on  lines 
a  a'  c  with  which  the  denudation  at  the  base  of  the 
penis  is  covered  (Berger  and  Hartmann). 


Fig.  207. — Operation  of  Reich  for  the  plastic  repair  of  denudations  of  the  skin  of  the  penis 
by  means  of  a  bridge  of  scrotal  tissue,  a  and  a! .  b  and  b'  representing  the  upper  and  lower  borders 
of  the  incision;  lower,  about  9  centimeters,  slightly  the  longer.  The  flap  having  been  freed,  the 
surface  of  denuded  shaft  of  the  penis  having  been  freshened  is  slipped  through  as  though  a  ring 
and  fastened  with  a  few  sutures  through  top  and  bottom  to  the  flap.  After  about  twenty  days 
the  ring  is  freed  by  incising  line  c  b  (redrawn  from  Berger  and  Hartmann). 


Eleven  days  after  he  cuts  each  side  line,  a  h  and  a'  h' .     He  uses 
the  sides  of  the  bridge  and  recovers  with  it  the  shaft  of  the  penis ; 


GROWTHS    AND   ULCERATIONS   OF   THE    PENIS  499 

then  he  takes  another  flap  and  recovers  with  that,  Hne  a  a'  c,  the 
base  of  the  penis. 

Fracture  of  the  organ  may  take  place;  this  is  in  reahty  a  frac- 
ture of  the  corpora  cavernosa.  The  injury  is  accompanied  by 
pain  and  sometimes  by  fainting;  the  organ  becomes  flaccid  and 
enormously  swollen.  Occasionally  this  is  complicated  by  a  rup- 
ture of  the  urethra.  As  a  rule  the  injury  is  followed  by  distur- 
bance of  the  sexual  functions,  as  after  healing  the  posterior  por- 
tion of  the  organ  may  become  rigid  at  times,  the  anterior  generally 
remaining  flaccid. 

Probably  the  best  treatment,  if  the  case  is  seen  early  enough, 
is  to  cut  down  on  the  organ,  remove  any  clots,  and,  by  means  of 
fine  sutures,  sew  the 
fractured  portions 
well  together,  apply- 
ing splints,  and  pre- 
venting, so  far  as  pos- 
sible in  the  after-treat- 
ment, the  formation 
of  cicatricial  tissue. 


GROWTHS  AND  UL- 
CERATIONS OF  THE 
PENIS 


Saddle-shaped    nod- 

ojIpc  nppndonnllv  fnrm        ^*^'     208.— Epithelioma  of  the   foreskin.     (Natural  size.) 
M-teo    \j\^\^a,3iyjiiaixy   iwiiii  From  a  specimen  111  the  museum  ot  Carnegie  Laboratory. 

in  the  corpora  caver- 
nosa and  spongiosum,  and  interfere  with  the  proper  performance 
of  the  sexual  function.  They  generally  occur  in  men  past  middle 
life,  and  there  is  much  diversity  of  opinion  regarding  their  origin. 
They  may  be  syphilitic,  gouty,  or  possibly,  in  certain  cases,  malig- 
nant. If  syphilis  is  suspected,  internal  and  local  external  treat- 
ment should  be  tried;  antiphlogistic  treatment  of  various  kinds 
may  also  be  effective.  If  these  fail  to  effect  their  removal,  sur- 
gical measures  should  be  undertaken,  but  a  guarded  prognosis 
should  be  given  as  regards  recovery  of  the  lost  sexual  function. 
Tumors  of  the  organ,  with  the  exception  of  carcinoma,  are  rare. 
Homy  excrescences  and  cysts  of  varying  size  occasionally  form, 


500 


THE   PENIS 


and  are  treated  as  successfully  as  are  cystic  formations  occurring 
elsewhere  in  the  body.  Cancer  of  the  penis  originates  from  the 
epithelium  of  the  glans  in  most  cases ;  it  occurs  almost  exclusively 
as  a  primary  growth  of  the  epitheliomatous  variety,  and  is  seen 
only  rarely  as  a  metastatic  process.  The  treatment  is  early  and 
complete  surgical  removal,  and  temporizing  measures  should  be 
adopted  only  in  inoperable  cases.  Ulcerations  on  the  glans  penis 
are  quite  common,  generally  being  either  chancre  or  chancroid, 
for  a  detailed  description  of  which  the  reader  is  referred  to  any 

of  the  text-books  on  sy- 
philis. Gumma  also  oc- 
curs, usually  as  an  ulcera- 
tive process,  and  where 
diagnosis  is  in  question, 
antisyphilitic  treatment  is 
always  advisable  in  cases 
of  ulcerated  neoplasms 
of  the  penis.  Tubercular 
ulcerations  may  occur, 
but  are  very  rare.  They 
should  be  treated  by 
appropriate  destructive 
agents,  such  as  carbolic 
acid,  followed  by  as- 
tringent dusting-powders. 
Ordinarily  chancre  and 
chancroid,  except  of  the 
phagedenic  type,  yield 
readily  to  local  treatment,  such  as  appHcations  of  carboHc  acid 
or  dusting-powders  like  aristol,  together  with  the  appropriate 
internal  treatment.  Chancroid  is  the  principal  cause  of  sup- 
purating inguinal  glands,  or  bubo,  which  may  be  mentioned 
here.  Bubo  is  the  term  applied  to  an  inguinal  gland  which  has 
suppurated.  The  treatment  of  this  condition  is  preventive  and 
operative.  The  preventive  treatment  consists  in  the  applica- 
tion of  vasogen-iodin  or  mild  mercurial  ointment  or  applications 
of  alcohol  on  gauze  covered  with  rubber  tissue,  together  with 
rest  in  bed.      If  suppuration  takes  place   the   gland  should  be 


Fig.  209. — Tuberculosis  of  the  glans  penis  (Frisch  and 
Zuckerkandl). 


FOREIGN  BODIES  IN  THE  URETHRA 


501 


opened  by  means  of  as  small  an  incision,  half  an  inch  or  more, 
as  is  practicable,  pus  evacuated,  and  iodoform,  10  per  cent,  in 
glycerin,  injected  three  times  into  the  cavitv,  injection  to  be 
repeated  on  following  day  and  again  in  four  or  five  days  if  re- 
quired. A  wet  dressing  is  to  be  kept  applied.  In  obstinate  cases 
it  may  be  necessary  to  make  a  large  opening  and  curet  the  cavity. 


Fig.  210.— Cancer  of  penis  and  scrotum  (author's  collectiuii). 

FOREIGN  BODIES  IN  THE  URETHRA 
The  literature  bearing  on  foreign  bodies  and  urethral  calculi 
in  the  urethra  is  very  extensive,  and  the  methods  recommended 


Fig.  211. — Thompson's  urethral  forceps. 

for  their  removal  are  numerous.  If  nature  fails  to  remove  an 
obstruction  and  simple  measures — such  as  distention  of  the  canal 
anterior  to  the  obstruction — fail,  an  effort  should  be  made  to 
grasp  the  body  by  means  of  long,  very  narrow  dressing  forceps 


502 


THE   PENIS 


designed  for  the  purpose.  Occasionally  small 
substances  may  be  removed  by  means  of  a  small 
curet  with  a  long  handle.  If  these  measures  do 
not  accomplish  the  desired  results,  an  incision 
should  be  made  over  the  shaft  of  the  organ  and 
the  obstruction  removed;  this  is  not  a  very 
serious  operation.  Or,  if  desired,  the  ordinary 
perineal  incision  may  be  made  and  the  sub- 
stance pushed  back  through  the  perineal  wound. 


HYPOSPADIAS 

Hypospadias,  or  fissure  of  the  inferior  ure- 
thra, is  ordinarily  a  congenital  condition,  and 
is  generally  divided  for  purposes  of  description  into  three  classes, 
of  which  the  first  is  the  most  common:  (i)  Hypospadias  of  the 


Fig.  212. — Beck's  op- 
eration for  hypospadias. 
The  urethra  freed. 


Fig.  213. — Fastening  hypospadiac  orifice  to  the  catheter. 


HYPOSPADIAS 


503 


.*. --^-Ir^i 


Fig.  214. — Dissecting  the  urethra  while  stretching  it  with  catheter. 


Fig.  215. — Beck's   operation    for  hypospa- 
dias.    Tunneling  the  glans. 


Fig.  216. — Beck's  operation  for  hypo- 
spadias. The  freed  urethra  brought  through 
the  tunneled  canal  in  glans. 


504 


THE    PENIS 


Fig.  217. — Catheter  with  urethra  drawn  through  glans;  insertion  of  suture. 


Fig.  218. — Beck's  operation  for  hypospa- 
dias. Suturing  the  skin.  Glans  trenched 
instead  of  tunneled. 


Fig.  219. — Beck's  operation  for  hypo- 
spadias. Suture  finished;  urethra  fastened 
in  tunneled  glans. 


HYPOSPADIAS 


505 


glans  of  the  penis.     (2)  Hypospadias  of  the  body  of  the  penis. 
(3)  Perineal  or  scrotal  hypospadias. 


Fig.  220. — Beck's  operation  for  hypospadias  showing  relaxation  sutures,  to  allow  for  tension: 
A,  Relaxation  suture  introduced  over  simple  suture;  B,  relaxation  suture  complete. 


Fig.  221. — Beck's  operation  for  scrotal  hypo- 
spadias.   Showing  line  of  incisions. 


Fig.  222. — Beck's  operation  for  scrotal  hypo- 
spadias.   Showing  new  formed  urethra. 


Operations  for  the  relief  of  this  condition  are  extremely  interest- 
ing and  deserving  of  more  consideration  than  can  be  given  them 


5o6 


THE   PENIS 


here.  When  the  penis  is  curved  downward  and  bound 
scrotum  by  adhesions,  it  should  be  cut  free  and  the  lateral 
sewed  longitudinally  by  the  method  of  Duplay. 

The  operation  of  Dr.  Carl  Beck, 
of  New  York,  is  the  one  advocated 
by  the  writers  for  the  relief  of  hypo- 
spadias of  the  glans.  It  is  divided 
into  three  parts,  which  are  well 
shown  in  the  illustrations  (figs. 
212  to  220  inclusive). 

Make  a  longitudinal  and  two  lat- 
eral incisions  on  each  side  of  the 
urethra,  and  dissect  from  the  sur- 
rounding tissue  for  an  inch  or 
two,   if   desired  aided   by  catheter 


to  the 
wound 


Fig.  223. — Beck's  operation  for  scrotal  hypo- 
spadias. Showing  flap  taken  from  scrotal  tissue 
twisted  on  itself  covering  new-formed  urethra. 


Fig.  224. — Instruments  used  in 
Beck's  operation  for  hypospadias,  a, 
Toothed  retractor ;  6,  toothed  adjust- 
able holding  forceps. 


in  urethra.  With  a  trocar  make  a  hole  through  the  top  of  the 
glans  to  the  urethra,  draw  the  urethra  through,  fasten  with  a 
few  stitches,  and  support  and  keep  open  for  a  few  days  with  a 


EPISPADIAS 


507 


retention  catheter,  thus  holding  it  in  place  until  it  unites.  Sew 
up  the  skin  wounds  at  the  base  of  the  glans.  Relaxation  sutures 
assist  to  overcome  tension.  Instead  of  tunneling  the  glans  may 
be  trenched. 

Operations  for  the  relief  of  hypospadias  occurring  high  in  the 
shaft  of  the  organ  are  of  the  same  character  as  those  performed 
for  hypospadias  occurring  in  the  glans.  When  situated  at  or 
near  the  scrotal  junction,  they  are  similar  to  those  performed  for 
perineal  hypospadias. 

Operations  for  the  Relief  of  Perineal  or  Scrotal  Hypospadias. — 
The  Beck  operation  is  here    probably  the 
best.     It  consists  of  making  several   flaps 
figs.  221,  222,  223): 

Beck  makes,  on  each  side  of  the  gutter 


Fig.  225. — T  h  i  e  r  s  c  h 
operation  for  epispadias. 
Narrow  lines  for  refresh- 
ing the  canal  in  the  glans. 
T  w  o  incisions  are  made 
which  if  prolonged  would 
meet  one  another.  First 
step. 


Fig.  226. — Thiersch  opera- 
tion for  epispadias.  Refreshing 
the  canal,  showing  lines  after 
the  suture,  the  segment  hav- 
ing been  taken  away  and  the 
side  walls  thus  refreshed  liga- 
tured together  over  a  sound. 
First  step. 


Fig.  227. — ^Thiersch 
operation  for  epispadias. 
Illustrating  lines  for  side 
flaps.     Second  step. 


and  parallel  to  it,  an  incision  sufficiently  long  to  reach  the  point 
of  the  new  urethral  orifice.  The  penis  being  Hfted,  he  unites 
these  two  incisions  by  a  third,  and  forms  a  flap  (separated  from 
the  penis  by  dissection)  which  he  folds  around  a  sound,  sutures 
its  two  edges  together,  and  thus  makes  a  new  urethra ;  the  second 
flap  he  bends  back  on  itself  to  form  a  surface  over  the  new 
channel;  this  flap  is  cut  from  scrotal  portion  in  the  form  of  a 
tongue  with  its  base  superior,  and  is  used  to  cover  the  denuded 
portion. 

EPISPADIAS 
This   condition  is  the   opposite  of  hypospadias — the   opening 
being  on  the  superior  aspect  of  the  organ.     It  is  also  an  accom- 


5o8 


THE   PENIS 


paniment  of  exstrophy  of  the  bladder.  The  opening  being  high, 
the  urethra  can  be  dissected  out,  brought  into  proper  position 
and  replaced,  and,  if  necessary,  a  small  flap  may  be  utilized  to 
cover  the  open  space.  Epispadias  in  which  the  opening  occurs 
at  the  base  of  the  shaft  of  the  organ  is  sometimes  met,  and  is  a 
much  more  difficult  condition  to  treat.  Probably  the  operation 
of  Thiersch  is  as  good  as  any.  It  demonstrates  what  may  be  and 
has  been  occasionally  successfully  done  in  the  way  of  performing 
a  plastic  operation.  First  refresh  and  unite  canal  in  glans  (figs. 
225,  226). 
In  fig.  227  two  flaps  are  shown,  taken  from  each  side  of  the 


Fig.  228. — ^Thiersch  operation  for  epi- 
spadias. The  right  flap  is  brought  over 
onto  the  raw  surface  of  the  turned  over 
left  flap.     Second  step. 


Fig.  229. — -Thiersch  operation  for  epi- 
spadias. The  prepuce  is  incised  and  pulled 
over  glans,  covering  freshened  edges  of 
corona  fistula.     Third  step. 


median  line  on  the  superior  surface  of  the  organ.  They  are  so 
united  that  they  come  in  contact,  raw  surface  to  raw  surface,  in 
the  ordinary  way,  thus  covering  over  the  open  canal  with  a  dura- 
ble roof.  The  next  step  in  this  interesting  operation  is  the  making 
of  a  foreskin.  This  Thiersch  does,  as  is  shown  in  the  illustration 
(fig.  229),.  by  making  a  button-hole  incision  in  the  redundant 
skin  hanging  down  like  an  apron  underneath  the  glans,  and  pulling 
the  glans  through  the  opening,  just  as  the  glans  penis  is  pulled 
through  an  opening  in  a  piece  of  gauze  often  used  as  a  dressing  in 
cases  of  urethritis;  the  skin  is  then  sutured  to  cover  coronal 
fistula.  The  opening  of  the  canal  has  now  been  closed  over,  the 
foreskin  made  and  sewed  in  place,  but  the  lower  end  of  the  ure- 


AMPUTATION   OF   THE   PENIS 


509 


thral  opening  at  the  base  of  the  organ  has  not  been  closed.  This 
the  operator  accompHshes,  as  will  be  seen  from  the  cuts  (figs. 
230,  231),  by  taking  two  winged-shaped  flaps  from  the  pubic 
region,  bringing  them  over  the  opening  in  a  manner  analogous 


Fig.  230. — Thiersch  operation  for  epi- 
spadias. Showing  two  flaps,  left  triangular, 
right  rectangular;  left  turned  over  orifice 
and  base  of  penis.     Fourth  step. 


Fig.  231. — Thiersch  operation  for  epi- 
spadias. The  rectangular  right  flap  has 
been  brought  over  on  to  the  top  of  left  flap. 
Wounds  caused  by  flap  removal  will  close 
by  granulation.     Fourth  step. 


to  the  flap  operation  on  the  shaft  of  the  penis,  and  securing  them 
according  to  the  method  shown  in  the  illustration. 

Almost  all  operations  for  the  relief  of  epispadias  and  hypospa- 
dias of  any  extent  require  a  perineal  section  in  order  that  the 
parts  may  be  kept  at  rest  while  healing  is  taking  place. 


AMPUTATION  OF  THE  PENIS 

This  operation  is  not  infrequently  performed  for  cancer,  and 
may  be  made  necessary  by  injury  or  gangrene.  In  the  main 
there  are  two  operations  for  the  relief  of  cancer  of  the  penis  or 
allied  conditions.  Both  are  comparatively  easy  to  perform. 
One  consists  of  entire  removal  of  the  organ,  and  the  other  of  the 
performance  of  amputation  in  continuity.  The  writers  recom- 
mend the  latter  operation  for  cancer,  as  the  operation  of  complete 
removal  of  the  gland  is  open  to  serious  objection. 

The  operation  for  entire  removal  is  performed  as  follows :  The 


5IO 


THE    PENIS 


legs  of  the  patient  being  elevated  and  the  proper  operative  toilet 
having  been  made,  an  incision  is  made  splitting  the  scrotum  down 
to  and  exposing  the  urethra;  then,  with  careful  dissection,  the 
corpora  cavernosa  are  dissected  awa}^  from  the  urethra,  this  canal 
being  allowed  to  hang  down  like  a  piece  of  tape.  The  corpora 
cavernosa  are  now  severed  at  their  connection  to  the  crest  of 
the  pubes;*  this  is  likely  to  cause  severe  hemorrhage,  and  Dr. 
Henry  H.  Morton  recommends  burning  off  the  corpora  cavernosa 
from  the  pubes  by  means  of  the  thermocauter}^  to  avoid  hemor-  ■ 
rhage.  After  the  corpora  cavernosa  have  been  removed,  the 
urethra  is  pulled  through  the  perineal  opening  and  stitched  to 


Fig.  232. — Amputation  of  penis  :  A,  A,  Method  of  making  dorsal  flap;  B,  B,  line  of  amputa- 
tion ;   C,  projection  of  urethra. 


its  edges.  Any  part  of  the  urethra  that  proves  too  long  for  the 
purpose  required  can  now  be  snipped  off.  As  has  been  observed 
by  Dr.  Morton  and  others,  with  whose  observations  the  writers, 
from  their  limited  experience,  are  in  accord,  the  objections  to  this 
operation,  which  is  a  comparatively  simple  one  to  perform,  and  is, 
in  its  way,  brilHant,  are  that  where  the  cancerous  process  has  ad- 
vanced so  far  as  to  demand  this  procedure,  death  from  extension 
of  the  process  or  from  infection  of  the  wound  rapidly  ensues. 
The  operation  of  choice,  then,  for  cancer  of  the  penis  is  to  amputate 
as  soon  as  a  positive  diagnosis  has  been  made. 


AMPUTATION   OF   THE    PENIS  51I 

A  word  as  to  the  diagnosis  between  gumma  and  cancer  of  the 
penis.  It  is,  in  certain  cases  at  least,  impossible  to  differentiate 
from  the  appearance  of  the  ulceration  alone.  In  a  case  seen 
in  the  service  of  one  of  the  writers  at  the  City  Hospital  the 
absence  of  a  syphilitic  history  and  the  clinical  appearance  of 
the  ulceration  seemed  to  point  conclusively  to  cancer.  A  sec- 
tion examined  microscopically  failed  to  show  the  presence  of 
cancerous  tissue.  The  pathologist,  however,  was  convinced, 
from  the  appearance  of  the  lesion,  that  the  specimen  was  can- 
cerous, although,  as  said,  microscopic  examination  failed  to 
prove  this.  An  active  course  of  antisyphilitic  treatment  was 
instituted,  but  the  ulceration  continued  to  spread.  Contrary 
to  the  judgment  of  the  house  staff,  and  in  spite  of  the  increas- 
ing ulceration,  operation  was  postponed,  and  the  antisvphilitic 
treatment  was  continued.  At  the  end  of  about  a  month,  when 
it  seemed  utterly  injudicious  to  delay  longer,  operation  was 
decided  on.  Before  the  day  of  operation  arrived,  however,  the 
ulceration  had  begun  to  improve  under  the  same  treatment  that 
it  had  so  long  withstood.  Healing  continued  with  astonishing 
rapidity,  and  in  a  period  of  about  two  weeks  complete  recovery 
ensued.  Although  there  was  no  evidence  to  substantiate  this 
view,  it  is  possible  that  the  method  of  administration  of  the 
antisyphilitic  treatment  in  this  case  was  faulty.  Since  this  time 
it  is  the  writers'  practice,  despite  the  clinical  appearance  and  the 
history  of  the  case,  to  advise  against  amputation  of  the  penis 
for  the  relief  of  cancer  until  thorough  antisyphilitic  treatment  has 
been  carried  out  for  several  weeks,  in  order  that  an  absolute 
diagnosis  may  be  arrived  at  before  operating. 

Amputation  of  the  penis  in  continuity  is  a  simple  operation  to 
perform,  and,  under  ordinary  circumstances,  gives  good  results. 
It  is  performed  as  follows:  Run  any  sharp,  pointed  instrument 
through  the  body  of  the  penis — hat-pins  have  been  popular  in 
the  past.  It  is  not  necessary,  as  was  formerly  done,  to  run  two 
instruments  through,  nor  is  this  done,  as  was  stated  by  some  of 
the  earlier  writers,  for  the  purpose  of  preventing  the  urethra  from 
slipping  back.  The  pin  is  run  through  merely  to  serve  as  a  point 
of  anchorage  for  the  ligature.  Pass  a  small  soft-rubber  catheter 
around  the  penis,  and  under  and  over  the  projecting  ends  of  the 


512 


the;  penis 


instrument  that  has  been  run  transversely  through  the  body  of 
the  organ,  tying  it  tightly  or  compressing  it  with  forceps  in  order 
to  prevent  hemorrhage.  Mark  the  point  at  which  it  is  desired  to 
amputate;  then  make  another  mark  on  the  body  of  the  penis, 
an  inch  or  so  in  advance  of  the  first  mark  on  the  superior 
aspect,  which  is  the  point  for  making  the  preliminary  incision. 
This  incision  should  go  only  through  the  skin,  and  is  made  for 
the  purpose  of  procuring  a  flap  for  the  corpora  cavernosa.  Dis- 
sect the  skin  back  until  the  mark  on  the  superior  surface  of  the 
organ  is  reached — the  point  at  which  the  actual  amputation  is 
to  be  done.     Next  cut  through  the  corpora  cavernosa  down  to. 


Ffg.  233. — Amputation  of  penis.     Method  of  sewing  together  the  sheath  of  the  corpora  caver- 
nosa and  the  splitting  of  the  urethra. 


but  not  through,  the  urethra.  This  will  leave  the  urethra  pro- 
truding, with  the  glans  of  the  penis  hanging  to  the  end  of  the  ure- 
thra. It  will  then  be  seen  that  each  of  the  corpora  cavernosa  is 
surrounded  with  a  sheath.  With  fine  ligatures  sew  the  sheath 
of  each  over  the  end  of  the  respective  corpus  to  prevent  hemor- 
rhage. Before  this  is  done  tie  off  any  bleeding  points  that  may 
be  left.  After  the  sheaths  have  been  carefully  stitched  over  the 
corpora,  attend  to  any  further  hemorrhage  that  may  exist.  Then 
cut  off  the  glans  from  the  end  of  the  urethra,  leaving  the  urethra 
protruding  about  a  half-inch  from  the  wound,  like  the  nozzle  of  a 
spout;    split  the  urethra  at  the  bottom,  take  one  stitch  through 


AMPUTATION   OF   THE    PENIS 


513 


the  comer  angle  of  the  urethra,  and  run  it  up  through  the  corre- 
sponding flap;  take  the  next  stitch  through  the  other  comer  of 
the  urethra,  and  run  it  through  its  corresponding  flap;  place  a 
few  sutures  in  between,  and  two  or  three  below.  It  is  a  matter 
of  little  importance,  apparently,  if  these  sutures  are  not  placed 
precisely  in  the  proper  manner  and  if  the  urethra  should  have  a 
slight  twist  at  the  point  of  the  amputation.  Remove  the  hat-pin 
or  other  instrument  that  was  first  used,  and  also  the  Ugature. 
Pass  a  large  sound  a  short  distance  so  as  to  be  certain  that  the 
urethral  opening  is  large  enough ;  introduce  a  catheter  a  demure, 


Fig.  234. — Amputation  of  the  penis.     Stitching  the  urethra  to  dorsal  flap  and  final  appearance 

of  stump. 


and  apply  a  suitable  dressing  to  the  wound.  Pay  particular 
attention  to  the  dressing  of  the  wound  for  the  first  three  or  four 
days  after  the  operation,  at  the  end  of  which  time  the  catheter 
may  be  removed,  or  it  may  be  allowed  to  remain  for  a  few  days 
longer.  After  the  catheter  has  been  removed,  under  ordinary 
circumstances,  a  good  stump  will  have  been  obtained,  and  the 
patient  will  be  able  to  urinate  with  a  comparative  degree  of  com- 
fort. In  performing  this  operation,  some  surgeons  are  accus- 
tomed to  remove,  at  the  same  time,  some  of  the  glands  from  the 
groin.  This  seems  to  the  writers  a  useless  procedure  unless  these 
nodes  are  known  to  be  involved.  The  illustrations  (figs.  232, 
233,  234)  show  this  operation  in  detail.  They  are  made  from 
33 


514 


THE    PENIS 


sketches  made  while  one  of  the  writers  was  amputating  for  relief 
of  a  phagedenic  chancroid. 

PHIMOSIS 

Phimosis  is  a  condition  in  which  it  is  impossible  to  retract  the 
foreskin  back  of  the  glans,  because  of  adhesions  or  inflammatory 
processes.  This  condition  is  famihar  to  most  practitioners.  It 
occurs  most  frequently  as  the  result  of  urethritis  or  of  uncleanli- 
ness ;  in  the  latter  case  the  smegma  which  has  been  allowed  to  col- 
lect between  the  inner  surface  of  the  foreskin  and  the  corona  of  the 
glans  becomes  infected,  and  luay  give  rise  to  a  discharge  that 
simulates  urethritis,  although  urethritis  may  not  be  present. 
This  latter  condition  is  commonly  known  as  balanitis  prseputialis. 
It  may  be  differentiated  from  true  urethritis  by  inserting  the  nozzle 
of  a  small  syringe  under  the  foreskin,  between  it  and  the  glans, 
washing  out  carefully,  and  then,  by  examining  the  meatus 
closely,  observing  whether  or  not  any  discharge  issues  from  its 
orifice.  Balanitis  may  exist  alone,  but  is  frequently  associated 
with  urethritis.  x\nother  common  cause  of  this  condition  is 
chancre  or  chancroid.  Phimosis  may  exist  for  a  considerable 
length  of  time,  and,  if  there  is  no  other  active  process  going  on,  is 
comparatively  harmless. 

The  treatment  for  the  rehef  of  this  condition  consists  of  frequent 
injections  of  a  simple  lotion,  such  as  lead  and  opium  wash,  between 
the  inner  surface  of  the  foreskin  and  the  glans;  this  solution  may 
also  be  applied  by  means  of  a  cotton  swab  wound  on  the  end  of  a 
small  stick.  Absolute  cleanliness  should  be  obser^-ed,  the  dis- 
charge and  decomposing  smegma  being  removed  two  or  three 
times  a  day. 

Operative  procedures  for  the  relief  of  this  condition  may  be 
instituted  at  any  time,  but  unless  there  are  urgent  indications, 
as  when  chancroid  is  present,  it  may  be  postponed  so  long  as 
an  acute  process  is  going  on.  If  the  phimosis  is  due  to  syphiHs, 
mercurial  plasters  may  be  strapped  over  the  foreskin,  mercurial 
washes  may  be  used  locally,  and  constitutional  antisyphilitic 
treatment  instituted;  these  measures,  by  causing  absorption  of 
the  chancre,  will  in  time  permit  the  foreskin  to  be  retracted. 
If  operative  treatment  is  decided  upon,  this  is  best  carried  out 


PARAPHIMOSIS 


515 


under  cocain  or  general  anesthesia:  By  means  of  strong  scissors 
make  a  longitudinal  incision  down  the  foreskin  on  each  side  of  the 
penis,  as  far  as  the  corona  of  the  glans.  This  will  make  a  lid 
of  the  upper  part  of  the  foreskin,  which  may  be  lifted  up  and 
then  cut  across  transversely.  This  effects  a  partial  circumcision. 
Another  Ud  will  be  left  by  this  operation  at  the  lower  surface  of 
the  penis.  This  lid  may  be  removed  at  the  time,  or,  better, 
amputated  a  week  or  two  later. 

After  phimosis  has  once  been  relieved,  as  it  ordinarily  can  be, 
by  the  use  of  cleansing  lotions,  the  patient  should  be  told  that  one 


Fig.  235. — Method  of  reducing  paraphimosis. 

attack  is  Hkely  to  predispose  to  another,  and  that  after  any  acute 
process  that  may  be  present  has  been  cured,  circumcision  should 
be  performed.  If  this  is  refused,  he  should  be  instructed  to 
observe  great  care  to  prevent,  by  daily  washing,  the  accumula- 
tion of  secretions  between  the  foreskin  and  the  glans. 


PARAPHIMOSIS 
Paraphimosis  is  a  condition  just  opposed  to  phimosis.     It  is 
the  result  of  a  tight  foreskin  having  been  pulled  back  of  the  glans, 


5i6  THE   PENIS 

some  inflammatory  condition  producing  a  contraction  that  makes 
it  impossible  to  bring  it  forward  by  means  of  ordinary  measures. 
Edema  and  temporary  deformity  of  the  organ  are  generally  asso- 
ciated with  the  condition,  and  tend  to  make  it  appear  more  serious 
than  it  really  is. 

Treatment. — Marked  edema  may  be  relieved  by  making  multi- 
ple punctures  with  a  needle,  squeezing  out  the  serum,  and  apply- 
ing hot  cloths.  By  holding  the  glans  of  the  penis  between  the 
first  two  fingers  of  each  hand  and  placing  the  thumb  of  each  hand 
over  the  meatus,  an  attempt  may  be  made,  by  making  gentle 
traction  with  the  fingers,  to  push  back  the  glans  underneath  the 
foreskin.  The  procedure  is  generally  successful.  If  the  condi- 
tion is  allowed  to  go  untreated,  ulceration  of  the  constricting 
band  may  take  place.  If  gentle  measures  fail,  an  incision  one 
or  two  inches  long  may  be  made  over,  down,  and  through  the 
constricting  band,  which  can  be  felt  just  back  of  the  corona. 


QRCUMCISION 

The  removal  of  an  excessively  long  foreskin  as  a  hygienic  meas- 
ure is  one  of  the  oldest  operations  known  to  surgery.  There  are 
several  methods  of  performing  circumcision,  the  choice  of  these 
depending  on  the  demands  of  the  individual  case.  For  an  acute 
phimosis  associated  with  chancroid,  circumcision  by  means  of 
lateral  incisions  made  on  each  side  of  the  foreskin,  as  described 
previously  for  the  relief  of  phimosis,  is  the  operation  of  choice. 
The  best  method  for  performing  circumcision  in  children  and 
infants  is  to  make  a  straight  incision  in  the  median  line  on  the 
superior  aspect  of  the  penis  through  the  foreskin  as  far  as  the 
corona,  one  being  also  made  through  the  membrane  to  the  same 
extent.  Retract  the  mucous  membrane  and  the  skin,  and  with 
the  thumb  break  down  any  adhesions,  being  sure  that  the  corona 
of  the  glans  is  entirely  free.  Insert  one  suture  in  each  upper  cor- 
ner of  the  incision,  in  order  to  hasten  the  adhesion  of  the  skin  and 
the  mucous  membrane.  A  little,  if  desired,  may  be  clipped  off 
each  corner  before  the  stitch  is  inserted.  Dress  the  wound  with 
a  wet  dressing,  such  as  lead  and  opium  wash,  keeping  compresses 
soaked  in  this  solution  over  the  wound  for  several  davs.     This 


CIRCUMCISION 


517 


method  of  operating  consumes  but  a  few  minutes,  and  is  by  far  the 
one  of  choice  with  children.  The  tabs  or  ears  that,  in  the  adult, 
tend  to  form  underneath  when  this  method  of  circumcision  is  per- 
formed, become,  in  time,  absorbed  in  the  child.  In  tuberculous 
children  or  in  those  in  poor  general  condition  a  severe  balanitis  is 
likely  to  follow  this  simple  operation.  Rest  in  bed  and  the  con- 
stant appHcation  of  a  soothing  dressing  will  cause  this  complica- 
tion, in  which  the  glans  may  become  very  much  excoriated,  to 
disappear  in  a  few  days. 


•iliiiiiilm. 


Fig.  236. — Circumcision  with  clamp.    Removing  tlie  foreskin. 


The  ordinary  method  of  performing  circumcision  on  an  adult 
is  as  follows : 

An  encircling  mark  should  be  made  on  the  foreskin,  parallel 
to  the  corona  glandis,  one-fourth  of  an  inch  in  front  of  the  margin 
of  the  corona  on  top,  and  underneath  the  glans  toward  the  frenum, 
one-half  to  three-quarters  of  an  inch  above  the  sulcus  of  the  corona. 
It  is  best,  as  a  rule,  to  perform  this  operation  under  general  anes- 


5i8 


the;  penis 


thesia — if  desired,  nitrous  oxid  gas  may  be  used  for  this  purpose; 
not  infrequently,  however,  local  anesthesia  is  employed.  In  such 
cases  cocain — 2  per  cent. — should  be  used  freely.  A  few  drops 
should  be  injected  into  the  tissues  of  the  foreskin  in  the  neigh- 
borhood of  the  mark  that  was  made  to  act  as  a  guide  for  the 
incision.  This  should  be  followed  by  the  application  of  a  clamp. 
Many  varieties  of  clamps  have  been  devised  for  this  purpose, 
but  for  one  familiar  with  the  operation,  almost .  any  large  one 
will  answer.      The  foreskin  having  been  pulled   over  the  glans 


Fig.  237. — Circumcision  with  clamp.     Splitting  of  the  membrane. 


and  clamped,  at  the  indicated  place,  by  a  quick  stroke  of  a  very 
sharp  knife,  the  foreskin  should  be  severed,  the  clamp  removed, 
and  any  bleeding  points  caught  up  with  artery  forceps.  The 
mucous  membrane  then  presents  itself  for  removal;  this  is  gene- 
rally the  most  painful  part  of  the  operation.  A  small  quantity  of 
cocain  .solution  should  be  injected  into  several  portions  of  the 
mucous  membrane,  and  then,  with  a  pair  of  sharp  scissors,  it 
should  be  incised  on  its  superior  border  down  to  within  a  quarter 
of  an  inch  of  the  severed  skin ;  next,  with  the  scissors,  cut  off  the 


CIRCUMCISION 


519 


Fig.  238. — Circumcision  with  clamp.    Trimming  the  membrane  and  sewing  membrane  and 

skin  together. 


Fig.  239. — Showing  method  of  performing  circumcision  without  a  clamp:  A,  Incision  in  the 
skin  ;  £,  skin  turned  back  like  a  cufi  and  membrane  incised. 


520 


the;  penis 


corners  of  the  membrane,  running  along  parallel  to  the  cut  surface 
of  the  skin  and  ending  at  the  frenum.  in  front.  The  skin  and 
mucous  membrane  should  be  sutured  together,  a  suflEicient  num- 
ber of  fine  catgut  hgatures  being  employed.     It  is  better  to  insert 


Fig.  240. — Showing  method  of  performing  circumcision  without  a  clamp  :  C,  Skin  pulled 
forward  and  incised  on  superior  aspect  to  meet  other  incisions ;  Z),  skin  and  membrane  dis- 
sected off. 


teSv■■■V:■■:-V.^:■■  - 


Fig.  241. — Circumcision  without  a  clamp:  £,  Appearance  after  dissection  of  skin  and  mem- 
brane ;  .F,  insertion  of  stitches. 


too  many  sutures  than  too  few.  The  penis  should  next  be  care- 
fully cleansed  and  the  sutured  surfaces  dusted  with  iodoformogen. 
A  narrow  strip  of  gauze  bandage  should  be  wrapped  about  the 


CIRCUMCISION  52 1 

wound  at  the  site  of  the  suture.  This  should  be  covered  with  a 
strip  of  zinc  oxid  plaster  of  the  same  width.  The  elaborate 
bandaging  occasionally  employed  is  unnecessary.  The  patient 
should  be  instructed  to  hold  a  small  pad  of  gauze  immediately 
under  the  meatus  when  he  urinates,  so  that  no  urine  will  enter 
the  wound.  After  the  operation  the  patient  should  be  put  to  bed, 
and,  if  cocain  has  been  used,  he  should  be  told  that  within  two 
hours  he  will  probably  feel  worse  than  he  did  immediately  after 
the  operation.  The  longer  the  patient  can  be  kept  quiet,  the 
better,  as  the  irritation  produced  by  walking  tends  to  retard  heal- 
ing. The  bandage  should  be  changed  frequently  and  great  clean- 
liness observed.  Under  proper  antiseptic  precautions,  serious  com- 
phcations  rareh',  if  ever,  follow  this  operation.  The  tendency  in 
performing  circumcision  is  to  remove  too  much  rather  than  too 
little  of  the  foreskin.  If  too  much  is  removed,  quite  a  long  period 
of  time  will  be  required  for  the  necessary  granulation  to  take  place. 
Our  illustrations  (figs.  236,  237,  238)  show  the  ordinary  procedure 
clearly.  Another  method,  and  a  good  one,  is  shown  in  the  illus- 
trations made  from  sketches  (figs.  239,  240,  241),  by  which  the 
foreskin  may  be  removed  by  the  aid  of  a  clamp. 
32 


CHAPTER  XXV 

THE  SEMINAL  VESICLES 

At  the  base  and  on  each  side  of  the  bladder  are  found  tubular 
sacs  that  unite  with  the  corresponding  vas  deferens  just  at  the 
ampulla.  They  are  lined  with  a  mucous  membrane  of  columnar 
epithelium,  resting  on  an  areolar  connective-tissue  basement 
membrane.  Outside  of  this  layer  is  a  smooth  muscular  coat 
that  is  united  by  strands  of  connective  tissue  to  an  external 
fibrosa.  The  seminal  vesicles  secrete  a  fluid  that  mingles  with 
spermatozoa,  forming  the  seminal  fluid;  they  may  also  serve  as 
reservoirs  for  the  storage  of  semen  just  prior  to  ejaculation. 

Diseases  of  the  Seminal  Vesicles. — The  diseases  of  the  seminal 
vesicles  have  of  late  years  received  a  considerable  amount  of 
attention  from  specialists.  Undoubtedly  there  is  pathologic  evi- 
dence to  support  the  views  of  many  who  have  written  concerning 
the  diseased  conditions  of  the  seminal  vesicles.  The  most  fre- 
quent form  of  seminal  vesiculitis  is  due  to  an  extension  of  a 
gonorrheal  process  from  the  posterior  urethra.  The  vesicles  may 
also  be  involved  in  tuberculous  processes,  or  may  be  the  seat  of 
invasion  of  malignant  growths.  The  inflammatory  condition  may 
be  of  a  catarrhal  nature,  or,  more  rarely,  abscesses  of  considerable 
size  are  seen.  Clinically,  from  the  writers'  experience,  diseases  of 
the  seminal  vesicles  are,  nevertheless,  of  comparatively  rare  occur- 
rence. Several  years  ago  the  writers  studied  a  series  of  1 1 6  cases 
of  urethritis,  in  every  one  of  which  the  prostate  and  the  region 
of  the  vesicles  were  examined  carefully  through  the  rectum;  in 
thirty  the  secretions  obtained  by  means  of  prostatic  massage, 
were  examined  microscopically  by  an  expert  pathologist.  In  not 
one  of  these  cases  was  there  any  evidence  pointing  toward  an 
involvement   of   the   seminal   vesicles.      As   to   the   question   of 

522 


PLATE  XIV 


body  of  bladder 


left  vas  deferens 


left  ureter 


ampulla  of  lefty 
vas  deferens 


prostate  gland,' 
(posterior  surface)       ^fe- 


jaculatory  duct 


The  urinary  bladder  with  the  seminal  vesicles,  the  ampulla  of  the  vasa 
deferentia,  and  the  prostate  seen  from  behind  and  below.  The  prostate  is 
partly  divided  longitudinally  (Sobotta  and  ^McMurrich). 


THE    SEMINAL   VESICLES  523 

involvement  of  the  seminal  vesicles  in  tuberculosis,  it  is  interest- 
ing to  observe  the  frequency  with  which  tuberculous  testicles 
having  a  thickened  and  indurated  cord  are  removed.  In  other 
words,  there  is  a  route  leading  directly  to  the  vesicles,  but  there 
is  rarely  evidence  of  vesicular  involvement  after  the  testicle  is 
removed.  From  a  clinical  standpoint,  the  vesicle  would  thus 
appear  to  be  an  organ  that,  while  open  to  infection,  is  only  excep- 
tionally involved  in  inflammatory  conditions  that  so  frequently 
attack  neighboring  structures. 

Vesiculitis  is  commonly  differentiated  from  chronic  posterior 
urethritis  and  chronic  inflammatory  conditions  of  the  prostate  by 
the  finding,  by  means  of  careful  rectal  examination,  of  a  small 
swelling,  of  the  shape  of  the  tip  of  a  glove-finger,  just  above  the 
prostate,  on  each  side  of  the  median  line.  If  the  swelling  is  slight 
and  situated  quite  high  up,  and  if  the  individual  to  be  examined 
is  inclined  to  be  corpulent,  a  long  finger  may  be  required  in  order 
properly  to  reach  the  mass.  As  an  aid  to  the  diagnosis,  the  find- 
ing of  pus  and  spermatozoa  in  the  secretion  massaged  from  the 
region  of  the  vesicle  by  a  finger  in  the  rectum  is  useful. 

The  clinical  symptoms  of  a  catarrhal  vesiculitis  of  a  chronic 
form  resemble  very  closely  those  of  a  chronic  posterior  urethritis 
or  prostatitis;  an  acute  seminal  vesiculitis  or  presence  of  a  large 
abscess  so  closely  resembles  an  acute  prostatitis  or  a  prostatic 
abscess  that  they  can  be  distinguished  only  with  difficulty. 

The  treatment  of  vesiculitis  is  very  similar  to  that  of  diseased 
conditions  of  the  prostate,  with  which  it  is  so  closely  alUed. 
Irrigations  of  the  bladder,  measures  tending  to  improve  the  gen- 
eral tone  of  the  patient,  and,  in  cases  where  it  is  indicated, 
massage  of  the  prostate  and  of  the  vesicles  are  useful.  When 
large  abscesses  form  that  do  not  break  into  the  posterior  urethra 
and  the  contents  of  which  cannot  be  expelled  by  massage,  oper- 
ative measures  may,  in  certain  cases,  be  required.  The  writers 
would  hardly  go  so  far,  however,  at  the  present  time  at  least,  as 
to  advise  the  performance  of  an  incision  through  the  perineum 
and  opening  and  drainage  of  the  vesicles  for  the  relief  of  such  a 
condition  as  gonorrheal  rheumatism,  unless  a  well-marked,  definite 
abscess  could  be  made  out ;  in  the  latter  case  it  is  subject  to  the 
same  surgical  laws  as  govern  the  treatment  of  an  abscess  occurring 


524 


THE   SEMINAL   VESICLES 


in  any  other  portion  of  the  body,  modified  by  knowledge  of  the 
function  and  the  position  of  the  vesicles.  If  an  operation  for  the 
release  of  pus  in  this  location  is  followed  by  relief  from  pain 
involving  various  other  portions  of  the  body,  it  is  what  is  naturally 


Fig.  242. — Kraske's  incision. 

to  be  expected  to  follow  the  opening  of  an  abscess  and  the  release 
of  pus  as  in  other  portions  of  the  body. 

There  are  several  incisions  that  may  be  used  for  the  purpose 
of  opening  or  for  effecting  removal  of  the  seminal  vesicles.  These 
incisions  are  described  in  detail  here,  as  they  will  be  found  useful 


Fig.  243. — Rydygier's  modification  of  Kraske's  incision. 

not  onlv  for  opening  an  abscess  in,  or  for  the  removal  of,  a  seminal 
vesicle,  but  also  for  opening  an  abscess  in  the  prostate,  for  general 
diagnostic  purposes  where  it  is  desired  to  explore  the  perirectal 
tissue,  and  for  the  relief  of  stricture  in  performing  external  ure- 


THB   SEMINAL   VESICLES  525 

throtomy  without  a  guide.     It  is  to  be  remembered,  however, 


Fig.  244. — ^\'an  Dittel's  incision. 


Fig.  245. — ^Kocher's  incision. 


Fig.  246. — Zuckerkandl's  incision. .. 

that  the  writers  do  not  advocate  their  use  ordinarilv  for  the 


526  the;  seminal  vesicles 

removal  of  an  enlarged  prostate,  preferring  other  routes.     The 


Fig.  247. — Senn's  incision.  No.  i. 


Fig.  24S. — Venn's  iiicisimi,  Ni 


Fig.  24g. — Fuller's  incision. 


number  of  incisions  that  have  been  named  for  their  originators 


THE   SEMINAL  VESICLES 


527 


is  so  large  that  it  would  be  very  difficult,  if  not  impossible,  to  decide 
which  one  was  best  suited  for  the  purpose.  The  Kraske,  the 
Rydygier,  and  the  Van  Dittel,  being  one-sided  incisions,  are  per- 
haps more  useful  to  the  rectal  surgeon.  The  Zuckerkandl  and 
the  Kocher  are  so  similar  that  they  should  be  considered  together. 
The  Senn  and  the  Fuller  differ  somewhat  from  the  other  incisions 
mentioned  and  from  each  other. 

In  the  Senn  operation  "a  median  perineal  incision  is  made,  as 


Fig.  250. — Opening  periprostatic  space ;  showing  cun,'ed  line  of  cleavage  between  the 
urethra  and  the  rectum;  recto-urethral  muscle  and  triangular  ligament  just  being  incised. 
Sketched  at  operation. 

in  an  external  urethrotomy,  and  the  urethra  is  laid  bare,  but  not 
opened;  from  the  lower  angle  of  the  median  incision  on  each  side 
lateral  incisions  are  then  carried  to  a  point  half-way  between 
the  anal  margin  and  the  tuberosity  of  the  ischium,  and,  chiefly 
by  means  of  blunt  instruments,  the  rectum  is  dissected  out  of 
the  way.  This  is  a  comparatively  bloodless  operation,  and  there 
is  not  much  danger  of  wounding  the  rectum.  The  wound  is 
opened  as  extensively  as  possible  with  deep  retractors,  and,  if 


528 


THE    SEMINAL   VESICLES 


considered  necessary,  an  incision  is  made  in  the  urethra  and  a 
finger  introduced  through  it  into  the  bladder,  acting  like  a  blunt 
hook,  will  help  to  push  the  prostate  and  vesicles  up  into  a  position 
within  reach  of  the  operators." 

In  the  operation  devised  by  Dr.  Eugene  Fuller,  of  New  York,  the 
incision,  as  will  be  seen  from  the  cut  (fig.  249),  begins  considerably 
further  back  than  where  the  Senn  incisions  terminate.  "From  a 
point  a  little  above  the  upper  border  of  the  coccyx,  and  just  inside  the 


Fig.  251. — Removal  of  seminal  vesicle  through  a  perineal  incision.  At  the  apex  of  the 
exposed  field  under  the  retractor  is  situated  the  membranous  urethra,  below  it  lies  the  pros- 
tate, and  below  the  prostate  the  seminal  vesicles.  Hugging  the  rectum,  the  capsule  is  incised. 
The  incision  is  macie  over  the  entire  length  of  the  vesicle  up  to  the  prostate  (Pierre  Duval). 


body  of  the  right  ischium,  two  converging  longitudinal  cuts  are  made 
which  extend  downward  and  slightly  inward,  keeping  just  within 
the  borders  of  that  bone,  passing  the  tuber  ischii,  and  ending  a 
short  distance  below  the  tuberosity  at  a  point  laterally,  and  about 
three-fourths  of  an  inch  anteriorly,  to  the  anterior  margin  of  the 
anus;  the  incision  on  the  left  and  that  on  the  right  correspond 
exactly  to  each  other.  The  transverse  incision  is  then  made, 
which  connects  the  converging  ends,  dividing  the  perineum  trans- 


the;  seminal  vesicles 


529 


versely  about  three-fourths  of  an  inch  anterior  to  the  anterior 
margin  of  the  anus ;  then  the  longitudinal  incisions  and  after  this 
the  transverse  one  are  deepened,  being  careful  to  keep  far  enough 
away  from  the  anus  to  avoid  wounding  the  sphincter  muscle. 
With  the  thumb  and  finger  of  the  left  hand,  in  the  rectum  and 
out,  the  flap  containing  the  rectum  is  then  pulled  up  out  of  the 
way,  the  cutting  being  done  with  the  right  hand,  the  fingers  in 
the  rectum  serving  as  a  guide;    the  object  is  to  incise  along  the 


Fig.  252. — Removal  of  seminal  vesicles.  The  capsule  is  opened.  Exposure  of  the  vesicle. 
The  vesicle  is  seen  to  the  right,  the  vas  deferens  with  its  ampulla  to  the  left,  on  the  external 
border  of  which  is  the  group  of  vessels  (Pierre  Duval). 

rectal  walls  as  closely  as  possible  without  wounding  them.  Blunt 
dissection  will  enlarge  the  incision  sufficiently  to  permit  the  pros- 
tate or  vesicles  to  be  attacked.  A  plentiful  number  of  sutures 
should  be  introduced,  a  space  for  gauze  packing  being  left  in  the 
middle  of  the  transverse  cut." 

It  should  be  borne  in  mind  that  a  very  large  abscess  in  close 
proximity  to  the  urethra  has  a  tendency  to  bulge  toward  the 
perineum.     This  being  the  case,  almost  any  semilunar  incision 
will  suffice  for  drainage. 
34 


530 


THE    SEMINAL    VESICLES 


The  various  incisions  into,  as  well  as  the  anatomy  of,  the  peri- 
neum have  been  recently  exhaustively  considered  in  one  of  the 
best  works  on  the  prostate  yet  written,  "  Enlargement  of  the 
Prostate,  its  Diagnosis  and  Treatment,"  by  John  B.  Deaver, 
Philadelphia,  1905. 

A  word  of  our  own  concerning  the  incision,  anatomy  of  the 
perineorectal  region,  and  appearance  of  the  space  between  the 
rectum,  bladder,  and  prostate :  If  as  an  aid  in  performing  pros- 
tatectomy by  means  of  some  form  of  prostatic  depressor  the 

prostate  is  pulled  down, 
a  straight  or  some  other 
form  of  incision  may 
answer  that  purpose ;  but 
if  it  is  desired  to  open  up 
the  space  mentioned,  only 
one  form  of  incision  can 
be  used  after  the  skin 
and  superficial  muscles 
have  been  incised,  and 
that  is  well  shown  in 
our  illustration  (fig.  250), 
the  dark  crescentic  line 
to  the  left  of  the  knife 
representing  the  natural 
line  of  cleavage  between 
the  rectum  and  urethra. 
This  illustration  is  made 
from  a  sketch  drawn 
while  one  of  us  was 
recently  operating  for  a  prostatic  abscess.  The  line,  it  will 
be  noticed,  resembles  closely  the  Zuckerkandl  incision.  Incis- 
ing at  the  point  shown  in  any  other  direction  would  wound 
either  the  urethra  or  rectum  or  strike  bone.  It  is  difficult, 
in  operating  to  open  up  this  space,  to  get  the  picture  as  shown 
in  anatomies.  It  is  well  to  remember  that  the  muscles  to  be 
cut  through  seem  to  be  bunched,  the  thickest  at  the  bulb. 
After  they  have  been  incised  the  space  opens  up.  In  performing 
the  operation  it  is  well  to  hug  the  rectal  wall  very  closely,  follow- 


Fig.  253. — Scheme  of  vascular  pedicle  of  vas  deferens 
and  the  seminal  vesicle.  To  the  right  is  the  ureter,  open- 
ing into  the  bladder.  Behind  the  ureter  lie  the  arteries 
and  veins  running  to  the  external  border  of  the  vesicle, 
the  artery  of  the  vas  lying  on  the  front  of  the  canal 
(Pierre  Duval). 


THE   SEMINAL   VESICLES 


531 


ing  the  general  directions  as  laid  down  in  the  description  of  the 
Fuller  incision.  The  appearance  of  the  opened  up  space  is  as 
shown  in  the  illustration  made  from  a  sketch  (fig.  271,  p.  576). 
If  the  seminal  vesicles  are  to  be  incised, a  long,  narrow-bladed  knife 
will  be  found  convenient.  We  prefer,  when  practicable  to  obtain 
it,  to  have  the  patient  in  the  knee-chest  position.  It  is  difficult  to 
keep  the  field  of  operation  clean,  but  there  seems  to  be  a  tendency 


Fig.  254. — Removal  of  seminal  vesicles.  The  vas  deferens  with  its  artery  is  ligated,  cut 
across,  and  turned  inward.  A  forceps  is  placed  over  the  group  of  vessels.  The  vessels  are 
ligated,  and  the  vas  deferens  and  vesicle  are  removed  en  masse  with  curved  scissors. 
Galvanocautery  applied  to  base  (Pierre  Duval). 


for  rapid  healing  following  these  incisions.  Illustrations  are  also 
exhibited  (figs.  251,  252,  253,  254)  to  show  the  method  by  which 
the  vesicles  may  be  entirely  removed,  an  operation  not  often 
necessary. 


CHAPTER  XXVI 

ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY  OF  THE 
PROSTATE  GLAND 

ANATOMY 

The  prostate  is  a  glandular  and  muscular  organ,  surrounding 
and  enclosing  the  posterior  urethra  and  situated  immediately  be- 
yond the  neck  of  the  bladder.  It  is  made  up  of  three  lobes — two 
lateral  and  one  median.  It  measures,  according  to  Ouain,  about 
one  and  one-half  inches  transversely,  one  and  one-fourth  inches 
vertically,  and  three-fourths  of  an  inch  longitudinally.  Its  size, 
however,  varies  greatly  in  different  individuals,  and  under  both 
physiologic  and  pathologic  conditions.  It  completely  invests  the 
prostatic  urethra,  in  the  floor  of  which  is  found  the  sinus  pocularis. 
Just  posterior  to  this  is  an  erectile  mass  of  tissue,  the  caput  gall- 
inaginis.  The  prostate  is  invested  by  a  dense  connective-tissue 
capsule  that  is  closely  united  to  the  supporting  structure  or 
interstitium  of  the  gland.  The  parenchymatous  tissue  is  made  up 
of  a  large  number  of  simple  and  compound  tubular  glands,  which 
empty  through  fourteen  or  fifteen  ducts,  arranged  equally  on  each 
side  of  the  median  ridge  of  the  posterior  urethra.  The  supporting 
stroma  of  the  organ  is  composed  of  connective  tissue  in  which 
are  found  abundant  masses  of  smooth  muscle,  which  render  the 
organ  contractile.  The  glandular  acini  are  lined  by  simple,  some- 
times stratified,  columnar  epithelial  cells,  which  produce  a  mucoid 
secretion.  Corpora  amylacea  are  frequently  found  in  these  acini 
under  physiologic  conditions,  but  are  present  in  greater  number 
in  many  pathologic  states,  particularly  such  as  cause  retention  of 
secretion. 

Embryologically,  the  organ  develops  from  structures  analo- 
gous to  those  from  which  the  uterus  of  the  female  develops,  and 
the  organ  is  sometimes  known  as  the  uterus  masculinus.  This 
fetal  relationship  to  the  uterus  is  further  exemplified  by  the 
glandular  and  muscular  arrangement  of  the  prostate,  and  also, 

532 


PLATE  XV 


middle  umbilical  ligament 


mucous  folds ' ' 

orifice  of  ureter 
trigonum  vesicae 

uvula  vesicae 

orifices  of  prostatic  ducts 
prostatic  portion  of  uretlira 

ejaculatory  duct 


muscular  coat 
mucous  coat 


ureteric  fold 
colliculus  seminalis 

prostate  gland 


urethral  crest 


The  urinary  bladder  and  prostate  seen  from  in  front.  The  structures 
have  been  laid  open  by  a  longitudinal  section,  and  the  interior  of  the  bladder 
further  exposed  lay  a  horizontal  slit  (Sobotta  and  Mc^Murrich) . 


CONGENITAL   DEFECTS  533 

to  a  certain  extent,  by  its  physiologic  activities  and  pathologic 
manifestations. 

The  vascular  supply  of  the  gland  is  derived  from  the  vesical, 
hemorrhoidal,  and  pudic  arteries.  The  veins  connect  with  those 
of  the  penis  anteriorly,  and  posteriorly  with  the  ramifications 
of  the  internal  iliac  vein.  The  nerves  are  derived  from  the  hypo- 
gastric plexus,  and  are  made  up  of  both  medullated  and  non- 
meduUated  fibers. 

PHYSIOLOGY 

The  prostate  secretes  a  tenacious  and  slightly  turbid  mucoid 
fluid,  which  is  discharged  into  the  urethra,  where  it  mingles  with 
the  spermatozoa  and  other  secretions  of  the  male  genital  glands. 
Its  addition  increases  the  viabilit}^  and  activity  of  the  sperma- 
tozoa, and  it  unquestionably  forms  an  essential  element  of  the 
male  genital  secretion.  There  is  evidence  suggesting  the  possibility 
of  the  prostate  being  the  point  of  origin  of  an  important  internal 
secretion,  but  as  yet  nothing  definite  can  be  said  in  this  regard. 

The  organ  develops  rapidly  in  size  at  the  time  of  puberty,  and 
in  old  age  ordinarily  undergoes  more  or  less  atrophy.  Its  activi- 
ties are  dependent  to  a  considerable  degree  on  those  of  the  tes- 
ticle, and  castration  causes  atrophy  in  a  great  number  of  cases. 
Although  the  organ  is  essentially  an  accessory  genital  gland,  it 
is  also  definitely  associated  physiologically  as  well  as  anatomi- 
cally with  the  urinary  organs,  and  assists  materially  in  the  function 
of  active  urination. 

CONGENITAL  DEFECTS 
Errors  in  development  are  not  frequent  in  the  prostate  gland. 
They  occur  most  commonly  associated  with  generalized  anomalies 
of  development  or  in  cases  of  marked  sexual  aberration.  Under- 
development of  the  gland  has  usually  been  found  present  in  cases 
of  retarded  sexual  development;  and  on  several  occasions  the 
writers  have  seen  almost  absolute  agenesis  of  the  gland  attending 
absence  of  sexual  instinct  and  function;  in  less  marked  cases  the 
size  and  number  of  glandular  acini  is  greatly  diminished.  As 
a  general  rule,  the  growth  of  the  prostate  corresponds  quite  closely 
to  that  of  the  testicles  in  the  same  individual,  and  in  cases  where 
this  organ  has  been  removed  in  early  life,  the  prostate  usually 


534     ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY   OF    PROSTATE 

remains  undeveloped    and   its   tissue   is    diflferentiated   from   the 
bladder-wall  only  by  microscopic  examination. 

Occasionally  one  finds  congenital  variations  in  the  posterior 
urethra;  it  may  be  unusually  narrowed,  very  tortuous,  and  in 
some  instances  traversed  by  strands  of  connective  tissue.  Marked 
abnormalities  may  also  exist  in  the  verumontanum.  The  writers 
have  recently  seen  a  case  in  which  this  appendage  was  congeni- 
tally  elongated  and  of  such  size  that,  when  congested,  the  entire 
lumen  of  the  urethra  was  occluded.  Great  variation  in  its  size 
exists  normally,  and  in  some  cases  almost  no  traces  of  it  are  to  be 
seen. 

INJURIES  OF  THE  PROSTATE 

On  account  of  the  anatomic  situation  of  the  prostate  gland, 
which  is  deeply  placed  between  the  rami  of  the  pubes,  direct 
traumatisms  but  seldom  reach  it.  Furthermore,  it  is  covered 
over  by  a  thick  layer  of  subcutaneous  and  perineal  fat,  so  that 
traumatisms  directly  applied  rarely  cause  injury  to  the  gland, 
even  though  they  may  damage  the  membranous  urethra.  In 
the  writers'  experience  falls  are  the  most  frequent  cause  of  injury 
to  the  prostate,  the  patient  having  fallen  astride  certain  sharp 
objects.  Some  forms  of  saddles,  particularly  the  older  type  of 
cavalry  saddle,  gave  rise  to  relatively  common  injuries  to  the 
prostate  as  a  result  of  contusions.  Even  with  the  admirably 
constructed  cavalry  and  cowboy  saddles  now  in  use  in  this  country 
injuries  occasionally  result  in  riding  unruly  or  frightened  horses. 
In  the  early  days  of  bicycling  injuries  to  the  prostate  were  not 
uncommon,  and  were  usually  due  to  blows  received  from  the 
unduly  prominent  saddle  prong  employed  in  the  earHer  models 
of  this  machine. 

Injuries  through  careless  instrumentation  are,  unfortunately,  still 
so  common  that  every  clinic  affords  numerous  examples  of  them. 

Traumatisms  to  the  prostate  gland  are  oftentimes  of  a  very 
serious  nature,  because  of  its  situation,  its  high  vascularity,  the 
difficulty  of  establishing  drainage  when  the  wound  is  infected, 
and  the  close  relationship  which  it  bears  to  the  urethra ;  even  rela- 
tively trifling  injuries  to  the  prostate  may  cause  cellulitis,  with 
urinary  extravasation  and  extensive  pelvic  gangrene,  or,  as  the 
histories  of  cases  show,  be  followed  later  on  by  malignant  disease. 


PROSTATITIS  535 

HYPEREMIA  OF  THE  PROSTATE 

This  condition  usually  follows  excessive  physiologic  stimulation. 
It  may  occur,  however,  as  the  result  of  obstruction  to  the  circu- 
lation, as  in  thrombosis  of  the  hemorrhoidal  veins,  which  is  seen  in 
inflammatory  conditions  of  the  rectum  or  in  hemorrhoids,  and  in 
some  cases  of  atrophic  cirrhosis  of  the  liver.  The  importance  of 
the  condition  lies  chiefly  in  the  fact  that,  as  a  result  of  this  pro- 
longed congestion,  true  inflammatory  lesions,  perhaps  with  inter- 
stitial hyperplasia,  may  follow.  There  can  be  but  little  doubt 
that  at  least  a  few  cases  of  prostatic  hypertrophy  may  result  from 
conditions  of  this  nature;  although,  as  will  be  discussed  further 
on,  the  writers  believe  that,  in  by  far  the  larger  number  of  cases, 
prostatic  hypertrophy  is  due  to  other  and  more  specific  causes. 

Anemia  of  the  prostate  may  result  from  generalized  anemia, 
but  it  is  seen  physiologically  in  5'outh  and  in  old  age,  where  it  is 
associated  with  underdevelopment  or  atrophy. 

PROSTATITIS 

Acute  prostatitis  may  result  from  metastatic  infection  or  from 
urethral  infections  extending  from  the  urethra  through  the  ducts 
and  into  the  bodies  of  the  prostatic  follicles.  The  process  may 
then  become  disseminated  throughout  the  entire  gland,  although, 
as  a  rule,  it  is  more  or  less  localized — often  to  a  single  lobe  or 
perhaps  to  only  a  few  acini.  Acute  prostatitis  may  be  set  up 
also  as  the  result  of  extensions  of  inflammatory,  and  particularly 
suppurative,  processes  of  the  surrounding  ischiorectal  structures. 
The  disease  may  be  anatomically  divided  into  simple  inflammatory 
and  suppurative,  according  to  the  degree  and  type  of  the  inflamma- 
tion present.  It  is  needless  to  say  that  by  far  the  larger  number 
of  cases  of  acute  prostatitis  follow  posterior  urethritis  of  gonorrheal 
origin.  There  can  be  Uttle  doubt,  however,  but  that  a  certain 
number  of  cases  follow  prostatic  hyperemia,  either  from  over- 
stimulation or  as  the  result  of  the  use  of  irritant  drugs  or  condi- 
ments. It  is  possible  that  a  small  number  of  cases  also  develop 
in  the  course  of  rheumatic  and  gouty  dyscrasige. 

The  changes  present  in  the  prostate  necessarily  depend  chiefly 
upon  the  origin  and  nature  of  the  etiologic  factor,  and  especially 


536     ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY    OF    PROSTATA 

on  its  location.  Suppurative  processes  are  particularly  prolonged 
on  account  of  the  difficulty  of  drainage  and  because  of  more  or 
less  urinary  infiltration  and  fermentation,  which  add  in  all  cases 
to  the  exciting  inflammatory  agents.  As  a  rule,  urethral  infection 
results  in  abscess  formation  of  greater  or  less  extent,  depending 
on  the  number  of  acini  infected  and,  to  a  considerable  degree, 
on  the  virulence  of  the  infecting  organisms.     On  account  of  the 


IT-'-" 


Fig.  255. — Microphotograph.     Acute  suppurative  prostatitis  following  gonorrheal  urethritis. 
a,    Broken-down  acini ;  5,  purulent  exudate. 

dense  nature  of  the  capsule  of  the  prostate,  most  abscesses  drain 
into  the  urethra,  which  they  naturally  penetrate  along  the  ducts 
of  the  diseased  gland.  Not  infrequently,  however,  the  pus  may 
point  and  rupture  into  the  perineal  tissues  or  even,  in  certain  cases, 
into  the  bladder  or  rectum. 

When  the  acute  prostatitis  is  diffuse  and  non-suppurative,  it  is 
more  likely  to  become  subacute  or  chronic  and  finally  to  result 
in  an  interstitial  hyperplasia  with  eventual  sclerosis  and  atrophy; 
or,  in  a  certain  number  of  cases,  hypertrophy  of  the  organ. 


HYPERTROPHY    OF    THE   PROSTATE  537 

Chronic  Prostatitis. — Chronic  prostatitis  is  unquestionably  a 
much  more  frequent  disease  than  it  is  usually  believed  to  be.  Its 
etiologic  factors  may  be  almost  exclusively  grouped  under  the 
head  of  acute  prostatitis,  long  continued,  and  of  chronic  hyperemia 
conditions  due  to  any  cause.  Its  anatomic  changes  may  be  classi- 
fied as  diffuse  and  localized.  The  former  occur  most  often  as  a 
result  of  hyperemia  or  of  acute  diffuse  prostatitis;  the  localized 
forms  usually  follow  abscess  formation  or  traumatic  conditions. 
The  pathologic  anatomy  of  chronic  diffuse  prostatitis  consists 
essentially  of  a  diffuse  hyperplasia  of  the  connective-tissue  frame- 
work of  the  organ,  sometimes,  it  is  true,  associated  with  glandular 
hyperplasia,  but,  as  a  rule,  chronic  diffuse  prostatitis  resulting 
from  interstitial  hyperplasia  causes  atrophy  of  the  glandular 
elements,  with  subsequent  fibrous  replacement. 

Chronic  localized  prostatitis  usually  consists  of  long-standing  sup- 
purative processes,  commonly  encapsulated  by  dense  connective- 
tissue  formation,  and  ordinarily  hmited  to  a  single  lobe  or  lobule, 
although  in  a  considerable  number  of  cases  diffuse  necrosis  or 
gangrene  takes  place,  so  that  the  entire  gland  may  become  con- 
verted into  an  abscess  cavity,  limited,  perhaps,  by  the  greatly 
thickened  capsule. 

When  the  chronic  localized  prostatitis  follows  healing  of  a  sup- 
purative process  or  is  a  result  of  traumatic  disease,  locahzed 
hyperplasia  takes  place,  with  the  production  of  masses  of  scar 
tissue,  at  first  highly  vascular  and  then  avascular. 

HYPERTROPHY  OF  THE  PROSTATE 

Hypertrophy  is  by  far  the  most  important  and  one  of  the  most 
frequent  affections  of  the  prostate  gland.  The  condition  undoubt- 
edly occurs  most  comm^only  in  old  age,  but  the  more  careful  ex- 
aminations that  are  now  made  in  genito-urinary  practice  tend  to 
establish  the  fact  that  the  condition  is  much  more  prevalent 
among  middle-aged  and  young  men  than  was  formerly  believed. 
Occurring  in  the  young,  the  most  insistent  symptoms  do  not,  as 
a  rule,  become  obvious  on  account  of  the  physiologic  activity 
and  possibiUties  of  the  tissues  at  this  age.  Thus,  for  example, 
although  there  may  be  some  obstruction  to  the  flow  of  urine, 
on  account  of  the  greater  resihency  of  the  tissues,  and  particularly 


538     ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY    OF    PROSTATE 

because  in  youth  the  contractions  of  the  bladder  are  more  forci- 
ble, the  symptoms  of  obstructed  urination  may  remain  for  a  long 
time  unobserved.  Furthermore,  the  writers  find  that  in  a  very 
considerable  number  of  senile  cases  a  careful  review  of  the  history 
will  serve  to  establish  the  fact  that  the  condition  has  developed 
gradually,  originating  probably  in  comparative  youth. 

The  chief  symptoms  of  the  disease  are  those  resulting  from  ob- 


Fig.  2s6. — Microphotograph  showing  histologic  changes  in  prostatic  hypertrophy  of  the 
fibroid  type.  The  glandular  elements  are  completely  replaced  by  hyperplastic  connective 
tissue. 

struction  to  the  flow  of  the  urine,  generally  associated  later  with 
infections  of  the  prostatic  tissue  or  of  the  bladder ;  and  it  is  only 
when  this  urethral  obstruction  develops  that  the  clinician's  atten- 
tion is  drawn  to  the  disease.  An  examination  reveals  the  presence 
of  an  enlarged  prostate.  It  is,  therefore,  to  be  expected  that 
marked  prostatic  hypertrophy  is  often  discovered  postmortem, 
when,  owing  to  the  fact  that  the  urethra  was  not  encroached  upon 
by  the   enlarging  gland,   no   symptoms  nor  clinical  signs  were 


HYPERTROPHY   OF    THE    PROSTATE  539 

found  detailed  in  the  history  of  the  case.  The  truth  of  this  state- 
ment has  been  confirmed  by  an  extensive  postmortem  experience. 

When  the  enlargement  is  most  pronounced  in  the  middle  lobe, 
clinical  signs  develop  soonest,  on  account  of  the  peculiar  situa- 
tion of  this  portion  of  the  prostate  body,  as  a  result  of  which 
enlargement  causes  earlier  obstruction. 

Before  discussing  minutely  the  etiology  of  prostatic  hvper- 
trophy,  it  seems  essential,  for  its  proper  understanding,  that  we 
first  acquaint  ourselves  with  the  pathologic  anatomy  of  the  con- 
dition. 


Tig.  257. — Acini  in  hypertrophied  prostate  filled  by  desquamated  cells  simulating  cancer  for- 
mation. 

Pathology. — Prostatic  hypertrophy  of  old  age  may  involve  the 
•entire  gland ;  on  the  other  hand,  the  hyperplastic  changes  produc- 
tive of  the  condition  may  be  entirely  or  largely  limited  to  a  single 
lobe.  As  has  already  been  intimated,  the  amount  of  disturbance 
that  results  is  dependent  chiefly  on  the  degree  of  obstruction  that 
exists  to  the  posterior  urethra;  there  also  appears,  however,  to 
be  an  undoubted  effect  on  the  extrusor  capabilities  of  the  bladder 
in  prostatic  hypertrophy  quite  independent  of  urethral  obstruc- 
tion.    In  most  cases  the  size  of  the  prostate  is,  therefore,  not  of 


54°      ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY    OF    PROSTATE) 


SO  much  clinical  significance  as  are  those  effects  on  the  function  of 
th^  urethra  and  bladder  that  follow  the  enlargement.  That  this  is 
so,  has  been  well  exemplified  in  numerous  cases  recently  reported, 
in  which  great  benefit  followed  the  removal  of  the  prostate  in 
cases  in  which  the  enlargement  was  not  extensive. 

Almost  from  the  first  hypertrophy  of  the  prostate  was  classed 
as  a  true  tumor  formation,  and  nearlv  all  the  earlier  observers 


W^or-'- 


f~^fiZ^T^. '  > 


'3ic^ 


-^^    a 


'"tS'^i'i    ..«•.  '_'"  -•^•.     ■%   "* 


Fig.  258. — Microphotograph.  Acute  hyperplastic  stage  in  hypertrophy  of  the  prostate- 
showing  active  proliteration  of  connective  tissue  in  the  production  of  fibroid  hypertrophy 
of  the  prostate,     a.  Fibroblasts;  d,  acinus. 

discuss  the  condition  w^ith  this  as  a  primary  assumption.  It  was,., 
however,  noticed  that  metastases  did  not  follow  in  the  wake  of 
these  supposed  tumors,  as  was  the  case  in  a  considerable  percen- 
tage of  true  tumors  of  similar  appearance.  Finally,  when  the  use 
of  the  microscope  became  general  and  it  was  employed  in  the 
study  of  prostatic  hypertrophy,  it  was  seen  that  the  struc- 
ture of  these  tumor-like  enlargements  of  the  prostate  was  almost 
identical  in  its  elements,  as  well  as  in  its  arrangement,  with  normal 
glandular  structure.     As  a  result  of  these  studies  the  condition 


HYPERTROPHY   OP   THE    PROSTATE 


541 


HOW  came  to  be  considered  as  really  of  the  nature  of  a  hyperplasia 
and  it  was  found  possible  to  classify  the  prostatic  hypertrophies, 
independent  of  their  form,  into  those  made  up  chiefly  of  fibrous 
tissue,  those  made  up  largely  of  muscle  tissue,  those  consisting  of 
glandular  elements,  and  finally  those  in  which  the  admixture  of 
these  elementary  structures  was  in  about  the  same  proportion 
as  in  the  normal  gland.     It  was  now  generally  conceded  that  the 


''-^: 


Fig.  25g. — Microphotograph  showing  production  of  connective  tissue  in  small  sclerotic  pros- 
tate. 


process  was  in  truth  more  in  the  nature  of  a  fibrous,  adenoma- 
tous, or  muscular  hyperplasia,  and  that  the  condition  was  not 
truly  neoplastic  in  origin.  Notwithstanding  this  plain  statement 
of  fact,  there  still  exist  many  text-books — and  among  them  excel- 
lent works  on  pathology — that  continue  to  treat  of  prostatic 
hypertrophy  as  a  tumor  formation,  pointing  out  that  the  develop- 
ment of  fibroid  tumors  in  the  analogous  female  organ,  the  uterus, 
is  of  similar  nature.  Although  the  majority  of  the  leading  text- 
books on  pathology  and  genito-urinary  surgery  have  discarded 
this  older  theory,  very  few  writers  attempt  to  explain  the  manner 
in  which  this  hyperplasia  is  excited,  and  why,  contrary  to  most 


542     ANATOMY,    PHYSIOIvOGY,   AND   PATHOLOGY  OF  PROSTATE 

other  hyperplastic  processes,  it  is  reported  almost  exclusively  in 
old  age  instead  of  in  youth,  where  it  might  more  reasonably  be 
expected  to  occur. 

For  the  purpose  of  determining  this  question  the  writers  under- 
took the  careful  study  of  fifty-eight  cases  of  prostatic  hypertrophy, 
and  published  the  results  in  an  article  in  the  Journal  of  the 
American  Medical  Association,  April  26,  1902.  Their  efforts  were 
especially  directed  toward  ascertaining,  if  possible,  the  nature  of 
this  hyperplasia  and  its  probable  causative  factors,  in  so  far  as  these 
could  be  learned  from  the  anatomic  aspects  of  the  condition. 
Briefly,  it  may  be  said  that  their  conclusions  have  been  in  full 
accord  with  the  results  of  the  masterly  studies  made  in  Krakow 
by  Ciechanowski.  Very  early  in  the  work  it  became  apparent 
that,  as  a  matter  of  fact,  there  were  but  two  types  of  tissue  hyper- 
plasia to  be  dealt  with,  namely,  a  hyperplasia  of  the  glandular 
tissue  and  one  of  the  connective  tissue.  In  none  of  these  cases 
were  the  writers  able  to  find  more  muscle  tissue  in  the  hyper- 
trophied  areas  than  had  existed  in  the  normal  tissue  of  the  area 
involved;  in  fact,  in  most  cases  atrophy  of  the  smooth  muscle 
was  well  in  evidence,  and  many  cases  had  proceeded  on  to  actual 
replacement  of  muscle  by  exudate  or  by  young  connective-tissue 
fibrils  and  cells.  It  was  then  found  that  there  was  a  distinct  dif- 
ference between  the  true  cases  of  myoma  of  the  prostate  gland  and 
those  of  prostatic  hypertrophy  of  old  age. 

In  the  other  variety  of  prostatic  hypertrophy,  which,  more- 
over, is  the  form  most  frequently  found  involving  the  middle 
lobe,  the  tumor  is  characterized  by  being  made  up  mostly  of 
glandular  tissue,  supported  by  a  more  or  less  well-defined  connec- 
tive-tissue stroma.  It  is  this  particular  form  that,  on  account  of 
its  close  resemblance  to  adenoma,  has  largely  substantiated  the 
tumor  theory  of  the  disease.  Careful  analysis  of  sections  so  cut 
and  orientated  as  to  unite  with  the  glandular  acini  of  the  normal 
portions  of  the  prostate  soon  convinced  the  writers  that  this  type 
was  also  to  be  included  as  merely  hyperplastic  and  not  as  truly 
neoplastic.  In  short,  it  was  found  that  all  varieties  of  prostatic 
hypertrophy  may  be  included  under  one  of  these  heads,  although 
the  conditions  are  frequently  associated  in  the  same  gland. 

Briefly  stated,  then,  the  cause  of  prostatic  hypertrophy  must 
consist  of  factors  chiefly  operative  during  old  age  and  that  are 


HYPERTROPHY   OF  THE   PROSTATE 


543 


capable  of  causing  growth  of  both  epithehal  and  connective-tissue 
elements  of  the  gland,  either  singly  or  together,  and  entirely 
distinct  from  the  formation  of  true  neoplasms. 

Careful  study  of  many  sections  from  the  fifty-eight  cases  of  pros- 
tatic hypertrophy  examined  has  fully  convinced  the  writers  that 
the  hypertrophy  is  really  inflammatory  in  origin.  It  was  possible 
to  demonstrate  in  every  case  either  inflammatory  exudation  or 


Fig.  260. — Microphotograph.    Hypertrophied  prostate  showing  atrophy  of  acini  in  the  fibroid 
type:     a,  Atrophied  and  sclerosed  acini  ;  b,  newly  formed  fibrous  tissue. 


interstitial  hyperplasia,  one  or  both  of  sufficient  degree  fully  to 
account  for  the  enlargement  of  those  glands  that  would  pre- 
viously have  been  classified  as  fibromatous  or  myomatous.  In 
all  these  cases  the  formation  of  granulation  or  cicatricial  tissue, 
just  as  in  any  chronic  productive  inflammatory  process,  is  clearly 
demonstrable;  and  from  the  structural  standpoint,  no  points 
of  divergence  are  to  be  made  out.  It  remains  then  but  to 
reconcile  with  these  findings  the  conditions  seen  in  adenom- 
atous hyperplasia,  which  is  found  not  only  independently,  but 
also  associated  with  the  fibrous  type  just  described.  Careful 
study  of  the  glands,  where  the  sections  are  taken  from  the  per- 
ipheral parts  of  these  cases,  shows  a  succession  of  cyst-like  cavities 
lined  with  epithelial  cells  showing  many  evidences  of  proliferation. 


544     ANATOMY,    PHYSIOIvOGY,    AND   PATHOI^OGY   OP  PROSTATE 

As  a  rule,  the  cysts  are  filled  by  desquamated  cells,  generally 
more  or  less  broken  down,  by  serum  and  amyloid  bodies,  by  mucus, 
and  by  other  evidences  of  abnormal  cell  activity.  In  other 
words,  the  picture  presented  is  that  of  an  adenomatous  growth  as  it 
might  occur  anywhere  in  the  body.  It  is  only  when  sections  are 
taken  from  the  ducts  of  the  glands  just  as  they  are  about  to  enter 
the  urethra  that  we  find  the  conditions  that  show  the  true  nature 
of  this  interesting  picture.  This  examination  has  shown,  in  every 
case  of  adenomatous  prostatic  hypertrophy,  that  the  ducts  are 
occluded  or  obstructed  from  the  pressure  of  an  inflammatory 
exudate  in  the  more  acute  cases,  or  by  hyperplastic  connective 
tissue  about  the  ducts  in  the  more  slowly  developing  cases.  It  is 
then  clearly  apparent  that  the  occlusion  of  these  ducts  causes, 
by  the  retention  of  secretion,  the  cyst-like  dilatations  of  the  acini; 
and  that  the  proliferation  of  the  alveolar  cells  first  keeps  pace 
with  the  dilating  saccule,  and  then,  continuing,  results  in  epithe- 
lial desquamation. 

From  this  description  of  the  pathologic  anatomy  of  prostatic 
hypertrophy  it  is  clearly  evident  why  we  have  the  fibrous  type  of 
enlargement  so  frequently  associated  in  the  same  gland  with  the 
adenomatous  form;  for  if  the  interstitial  hyperplasia  originate, 
or  be  more  marked  in,  the  peripheral  parts  of  the  gland,  the  result 
is  that  the  acini  become  compressed,  atrophied,  and  replaced  by 
connective-tissue  growth,  whereas  if  the  process  originate  in,  or  be 
most  marked  in  or  about,  the  ducts,  occlusion  of  these  passages 
follows  and  the  gland  saccules  become  converted  into  adenoma- 
like cysts.  The  writers'  conclusions  in  this  respect  completely 
corroborate  the  anatomic  findings  of  Ciechanowski  and  of  other 
observers. 

Taking  for  granted  that  this  view  of  the  pathologic  anatomy 
of  prostatic  hypertrophy  is  correct,  one  can  then  place  no  other 
interpretation  on  the  etiology  of  the  condition  than  that  it  is 
most  certainly  inflammatory.  Reasoning  purely  from  the  ana- 
tomic standpoint,  but  remembering  the  enormous  variation  and 
range  of  inflammatory  processes,  it  must  be  conceded  that  the  con- 
dition might  be  induced  by  any  conditions  or  factors  that  will 
cause  the  development  of  an  inflammatory  process  in  any  portion 
of  the  gland. 

Certain  of  these  factors  have  already  been  considered  under 


HYPERTROPHY  OP  THE   PROSTATE  545 

the  heading  of  acute  and  chronic  prostatitis.  There  is  no  question 
in  the  writers'  mind  but  that  inflammatory  processes  in  the  pros- 
tate, of  whatever  nature,  might  thus,  as  in  any  similar  condition, 
bring  about  these  hypertrophic  changes;  which,  as  in  all  other 
organs,  tend  to  occur  more  often  in  senile  than  in  youthful  patients. 
In  a  considerable  number  of  cases  the  writers  were  able  to  con- 
nect the  inflammatory  areas  of  the  prostate  directly  with  periure- 
thral inflammation,  and  they  again  coincide  with  Ciechanowski  in 
his  conclusion  that  the  most  frequent  cause  of  prostatic  hyper- 
trophy is  a  primary  posterior  urethritis,  usually  of  gonorrheal 
origin.  With  this  admission,  however,  it  is  not  desired  to  exclude 
other  factors  of  inflammatory  nature,  such  as  might  follow,  for 
instance,  prolonged  congestion  with  the  production  of  new  fibrous 
tissue ;  nor  would  the  writers  exclude  other  bacterial  inflammatory 
processes,  although  they  believe  that  by  far  the  larger  number  of 
cases  follow  as  a  natural  sequence  on  posterior  urethritis. 

During  the  past  fifteen  years,  since  these  views  were  published 
by  Ciechanowski,  by  ourselves,  and  confirmed  by  others,  the  main 
objection  brought  against  them  has  been  that  an  acute  posterior 
urethritis  did  not  immediately  cause  prostatetic  hypertrophy. 
This  has  never  been  claimed  by  us;  it  is  the  after-result  of  the 
formation  of  cicatricial  tissue  resulting  from  such  conditions.  It 
has  also  been  claimed  that  if  the  pathology  was  as  reported,  cystic 
growth  would  occur  with  very  great  frequency.  This  is  not 
necessarily  the  case,  the  inflammatory  process  being  too  slow  a  one 
to  cause  a  sudden  blocking  of  the  acini,  which  might  result  in  a 
cyst. 

Apparently,  not  through  the  work  of  the  surgeons,  but  by  the 
work  of  the  pathologists,  the  after-result  in  inflammatory  condi- 
tions are  being  considered  of  more  importance,  both  in  the  causa- 
tion of  prostatetic  hypertrophy  and  cancer.  So  far  as  we  are  aware, 
all  investigators  who  have  made  sections  of  the  prostate,  com- 
mencing at  the  mouths  of  the  acini  where  they  open  into  the  floor 
of  the  prostate,  have  endorsed  our  views.  Naturally  those  sections 
made  through  the  center  of  the  prostate  still  give  rise  to  confusing 
opinions.  Considerable  importance  has  recently  been  ascribed  to 
the  role  played  by  the  periprostatic  glands.  Very  probably  they, 
too,  are  affected  in  a  somewhat  similar  manner  as  the  after  result 
of  inflammatory  conditions  as  is  the  prostate  itself. 
35 


CHAPTER  XXVII 

DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE 

PROSTATE 

From  the  preceding  chapter,  dealing  with  the  anatomy,  phy- 
siology, and  pathologic  anatomy  of  the  prostate,  the  importance 
of  the  proper  treatment  of  inflammatory  conditions  of  the  deep 
urethra — posterior  urethritis — will  be  apparent.  Ordinarily,  the 
treatment  must  be  most  careful  and  prolonged,  lest  so  serious  a 
condition  as  hypertrophy  of  the  gland  follow  as  a  sequel.  Much 
of  the  future  improvement  in  the  treatment  of  prostatic  diseases 
will  undoubtedly  be  along  the  line  of  preventive  measures.  It  is 
difficult  to  comprehend  how  such  conditions  as  prostatic  hyper- 
trophy, with  incontinence  of  urine,  and  chronic  cystitis  of  many 
years'  standing,  altering  the  entire  character  of  the  mucous  mem- 
brane of  the  bladder,  could  ever  be  cured  entirely  or  even  improved 
to  a  much  greater  extent  than  is  now  possible.  When  we  con- 
sider the  ill  effects  that  follow  acute  inflammatory  processes  in 
the  prostatic  urethra,  and  the  serious  consequences  that  result 
from  the  formation  of  scar  tissue,  it  will  readily  be  understood 
that  measures  directed  toward  the  prevention  of  such  formation 
would  prove  of  the  greatest  value.  Primarily,  then,  all  measures 
that  tend  to  prevent  or  cure  inflammatory  conditions  occurring 
in  the  prostatic  urethra  are  essential.  It  is  to  be  hoped  that  a 
better  understanding  of  the  serious  after-effects  of  gonorrhea, 
irregularities  in  the  sexual  life,  irritations  from  urinary  deposits, 
and  an  earlier  recognition  of  tuberculous  infections  will,  in  the 
future,  diminish  the  number  of  sufferers  from  prostatic  disease. 

ACUTE  PROSTATITIS 

Symptoms  and  Diagnosis, — The  fact  that  the  majority  of  cases 

of  acute  anterior  urethritis  are  associated  with  acute  posterior 

urethritis   is   so  well   known   as  to  require   no    discussion   here. 

Either  acute  or  chronic  posterior  urethritis  is  almost  always  asso- 

546 


CHRONIC   PROSTATITIS  547 

ciated  more  or  less  with  prostatitis,  and  with  the  methods  at  present 
at  our  command  it  is  difficult  to  differentiate  very  closely  between 
acute  posterior  urethritis  and  acute  prostatitis.  CHnically,  a  case 
of  acute  posterior  urethritis  that  presents  considerable  swelling  in 
or  around  the  prostate,  as  ascertained  by  rectal  touch,  tenderness, 
painful  sensations  in  the  region  of  the  prostate,  and  a  feeling  of 
weight  and  uneasiness  in  the  perineum,  is  generally  considered  to 
be  one  of  prostatitis.  If,  in  addition,  the  urine  or  pus  expressed 
by  massage  shows  prostatic  elements,  the  diagnosis  can  be  made 
with  certainty. 

Treatment. — This  resembles  closely  the  treatment  of  acute 
posterior  urethritis  and  later  that  of  chronic  prostatitis,  and  is 
very  similar,  also,  to  that  of  chronic  posterior  urethritis.  In 
attacks  of  acute  prostatitis  attended  with  painful  urination,  and 
especially  if  accompanied  by  a  rise  of  temperature,  rest  in  bed  and 
a  light  diet  should  be  insisted  on,  together  with  the  internal 
administration  of  such  drugs  as  will  relieve  the  pain ;  proper  local 
external  applications  of  heat  or  cold  should  also  be  made.  If 
deemed  advisable,  leeches  may  be  applied  to  the  perineum,  or  the 
perineum  may  be  blistered.  No  local  intraurethral  application 
should  be  made  to  the  posterior  urethra  while  acute  symptoms 
exist.  This  treatment,  conducted  for  a  period  of  from  four  or 
five  days  to  as  man}^  weeks,  should  cause  the  acute  symptoms  to 
subside,  when  the  treatment  of  chronic  prostatitis,  which  now 
ensues,  should  be  begun.  Occasionally,  however,  patients  with 
acute  prostatitis  grow  worse,  and  abscess  of  the  prostate,  requir- 
ing surgical  interference,  develops. 

CHRONIC  PROSTATITIS 
Diagnosis  and  Symptoms. — The  differential  diagnosis  of  chronic 
prostatitis  from  chronic  posterior  urethritis  is  very  difficult, 
the  symptoms  being  almost  alike  and  the  conditions  closely  allied 
clinically.  The  term  chronic  prostatitis  implies  an  inflammatory 
condition  of  the  posterior  urethra,  in  addition  to  which  the  symp- 
toms pointing  toward  a  prostatic  involvement  are  well  marked, 
and  prostatic  elements  are  present  in  the  expressed  secretion; 
in  posterior  urethritis  the  inflammatory  condition  is  believed  to 
be,  to  a  great  extent,  situated  in  the  posterior  urethra  alone. 


548        DIAGNOSIS    AND   TREATMENT   OF    PROSTATIC    DISEASES 

Before  making  a  diagnosis  of  chronic  prostatitis,  a  careful 
examination  of  the  urethral  exudate  (p.  114)  should  be  made. 
A  review  of  this  condition,  as  the  result  of  the  examination 
of  116  cases  of  urethritis,  was  made  by  one  of  us  in  asso- 
ciation with  Dr.  Blanchard,  the  pathologist  at  the  City  Hospital 
some  ten  years  ago,  and  microscopic  findings  in  cases  of  pros- 
tatitis so  discovered  exhaustively  studied.'  Roughly  speaking, 
if  the  urethra  has  been  washed  out,  the  patient  made  to  urinate 
in  three  glasses,  then  the  prostate  massaged,  and  the  patient  again 
urged  to  urinate,  the  small  amount  of  urine  collected  will  be 
found  to  be  somewhat  cloudy  if  the  normal  prostate  has  been 
massaged.  If  prostatitis  is  present,  the  urine  will  be  found  to  be 
more  or  less  coarsely  turbid,  and  will  also  contain  more  shreds 
than  in  the  cloudy  urine  from  the  massage  of  the  healthy  prostate. 

The  clinical  symptoms,  such  as  pain  in  the  region  of  the  prostate 
or  perineum,  increased  frequency  in  urination,  tenesmus,  dis- 
turbance of  the  sexual  functions,  and  symptoms  of  neurasthenia, 
all  point  toward  prostatic  involvement.  The  examination  of  the 
prostate  by  the  rectum  is  useful,  as,  in  every  case  of  those  recorded 
by  us  in  the  article  just  referred  to,  some  change  in  the  prostate 
could  be  made  out  by  the  examining  finger.  The  enlargement 
present  in  the  majority  of  cases  seems  to  be  located  in  one  lobe, 
or  at  least  most  marked  there. 

Treatment. — This  is  similar  to  the  treatment  of  chronic  poste- 
rior urethritis;  more  good  may,  however,  be  expected  to  result 
from  the  employment  of  purely  local  measures,  such  as  massage 
of  the  prostate;  the  nervous  system  is  likely  to  be  involved, 
and  more  attention  must  therefore  be  directed  toward  improving 
the  general  tone  than  is  required  in  the  treatment  of  chronic 
posterior  urethritis.  The  ordinary  local  treatment  generally  con- 
sists either  of  irrigations  or  of  instillations  into,  or  of  dilations  of, 
the  posterior  urethra. 

In  commencing  the  treatment  of  chronic  prostatitis  it  is  well 
to  tentatively  make,  through  a  small  French  silk  catheter,  a  few 
irrigations,  at  intervals  of  from  one  to  three  days,  of  four  ounces 

^"Observations  on  the  Prostate,"  by  Robert  Holmes  Greene,  "Journal  of 
the  American  Medical  Association,"  i8qS. 


CHRONIC    PROSTATITIS  549 

of  the  Ultzmann  solution  of  phenol,  alum,  and  zinc  sulphate,  of 
each,  from  i  :  looo  to  i  :  500.  If  these  are  well  borne,  later  irriga- 
tions of  silver  nitrate  i  :  10,000,  made  at  the  same  intervals,  are 
recommended,  or  irrigations  of  albargin,  from  i  :  2000  to  i  :  1000, 
may  be  tried.  In  place  of  the  irrigations,  instillations  of  a  few 
drops  of  silver  nitrate  solution,  one  or  two  to  one  grains  to  the 
ounce,  may  be  used  at  intervals  of  from  three  to  five  days.  After 
the  first  two  weeks  of  such  treatment  dilation  of  the  posterior 
urethra  should  be  performed  with  a  Kollmann  dilator,  and  re- 
peated once  in  five  days  or  once  a  week,  gradually  extending 
the  size  of  the  dilator  until  the  urethra  can  be  dilated  to  No.  40 
or  one  or  two  numbers  above.  It  is  well  then,  if  the  patient  can 
be  kept  under  observation,  to  continue  the  dilation  at  intervals 
of  at  least  once  a  month.  In  properly  selected  cases  massage  of 
the  prostate  may  be  practised  as  an  adjunct  to  the  foregoing  treat- 
ment. If  it  appears  to  benefit  it  may  be  repeated  as  often  as 
the  other  treatment  is  carried  out  or  at  separate  sittings. 

As  previously  indicated,  the  local  treatment  of  these  cases  should 
extend  at  gradually  lengthening  intervals  over  a  period  of  from 
several  weeks  to  months,  in  order  to  be  successful.  Confidence 
on  the  part  of  the  patient  and  patience  on  the  part  of  the  surgeon 
are  requisite. 

It  is  difficult  to  determine  when  these  sufferers  from  chronic 
prostatitis  or  chronic  posterior  urethritis  may  be  declared  entirely 
cured.  This  question  is  practically  that  of  the  curability  of 
gonorrhea.  The  absence  of  shreds  in  the  urine  is,  so  far  as  it 
goes,  a  good  indication,  but  they  may  recur  at  any  time,  and  no 
surgeon  is  justified  in  pronouncing  a  patient  permanently  cured 
because  of  their  temporary  absence.  The  mere  fact  of  the  presence 
or  absence  of  the  gonococcus  in  the  secretion  milked  from  the 
prostate,  while  it  has  some  clinical  significance,  does  not  prove 
absolutely  that  a  patient  has  or  has  not  been  entirely  cured.  In 
the  first  place,  it  must  be  remembered  that  unless  the  observer 
has  had  considerable  experience,  he  may  not  be  able,  by  staining 
methods,  definitely  to  distinguish  the  gonococcus  from  other 
diplococci.  Culture-tests  demand  a  trained  technician,  and  are 
carried  out  ordinarily  with  great  difficulty.      Then,  too,  the  ab- 


55°         DIAGNOSIS    AND    TREATMENT    OF    PROSTATIC    DISEASES 

sence  of  the  gonococcus  at  any  given  examination  does  not  nec- 
essarily mean  that  it  may  not  be  again  found  in  an  examination 
made  later. 

When,  under  proper  observation  at  repeated  examinations,  the 
gonococci  diminish  in  number  and  finally  disappear;  when  the 
amount  of  pus  is  seen  to  diminish  and  no  more  pus-cells  appear 
•microscopically;  when  the  symptoms  improve,  so  far  as  regards 
indefinite  pains,  painful  micturition,  or  pain  connected  with  the 
functionating  of  the  sexual  apparatus;  when  the  urine  and  dis- 
charge from  the  prostate,  obtained  by  massage,  clear  up — the 
patient  may  be  pronounced  as  practically  cured.  He  should  then 
be  advised  to  present  himself  occasionally  for  observation,  and  he 
should  be  informed  that,  as  the  result  of  dissipation  or  exhaustion 
from  some  intercurrent  disease,  his  troubles  may  return  without 
reinfection  taking  place.  One  of  the  questions  often  asked  the 
surgeon  is  as  to  the  probability  of  the  former  patient  carrying 
infection  to  others.  In  giving  advice  on  this  point  the  surgeon 
should  exercise  care  and  discrimination,  and  should  be  guided  by 
the  circumstances  surrounding  any  given  case.  Generally  speak- 
ing, a  patient  should  not  be  advised  to  marry  unless  his  urethra 
is  in  such  condition  as  to  indicate  cure;  those  who  are  already 
married  when  infected  should  also  receive  prohibitive  advice 
unless  the  indications  pointing  to  cure  can  be  satisfactorily  met. 
It  should  also  be  remembered,  first,  that  a  great  many  women, 
both  married  and  unmarried,  present  somewhere  in  their  urethral 
or  genital  apparatus  evidences  of  a  chronic  inflammatory  process 
that  is  not  necessarily  associated  with  any  impurity  on  their  part ; 
and,  second,  that  kindly  nature  seems  to  have  arranged  that  in 
many  cases  where  men  and  women  Uve  together  they  become, 
as  it  were,  immune  to  each  other's  infecting  organisms. 

Prostatic  Massage. — The  value  of  prostatic  massage  in  chronic 
prostatitis  can  be  determined  only  by  experiment ;  when  properly 
applied,  it  is  frequently  of  use.  On  the  other  hand,  if  improperly 
given  or  if  applied  to  unsuitable  cases,  harmful  results  follow.  The 
writers  were  among  the  first  in  this  country  to  observe  the  effects 
of  this  mode  of  treatment.  In  1894  it  was  adopted  by  the  Royal 
Institute  of  Massage  at  Stockholm.     In  that  year  this  procedure 


CHRONIC   PROSTATITIS 


551 


was  carried  out  by  a  graduate  of  that  institution  under  the  per- 
sonal direction  of  the  writers  on  a  patient  with  chronic  prosta- 
titis. The  observations  made  at  that  time  were  that  the  swelHng 
in  the  prostate,  as  observed  by  examining  it  through  the  rectum. 


Fig.  261. — Method  of  performing-  massage  of  the  prostate. 

was  thereby  diminished,  but  that  the  condition  of  the  patient 
was  not  materially  improved.  The  method  of  procedure  advo- 
cated at  that  time  was  to  massage  around  the  prostate  with  a 
circular  rotatory  motion  of  the  forefinger,  but  not  to  massage 
directly  over  the  gland  itself — the  same  procedure,  in  fact,  that 
skilful  masseurs  adopt  for  the  relief  of  an  acutely  inflamed  knee- 
joint,  the  object  being  to  stimulate  circulation  in  the  part,  by 
performing  massage  over  the  blood-vessels  surrounding  it,  and  to 
diminish   the   danger   of  increasing  the   acute   inflammation   by 


552        DIAGNOSIS   AND   TREATMENT    OF    PROSTATIC    DISEASES 

massaging  directly  over  it.  The  writers  believe  that  this  is  the 
safest  method  in  performing  massage  of  the  prostate.  In  acute 
inflammatory  conditions,  such  as  a  very  acute  prostatitis  or  acute 
posterior  urethritis,  it  is  best  to  avoid  massaging  the  prostate, 
and  the  same  holds  good  as  regards  the  seminal  vesicles.  Shortly 
after  1894  massage  of  the  prostate  came  into  popular  use,  and  is 
still  employed  by  many  surgeons  in  the  treatment  of  chronic 
prostatitis,  the  object  being  to  press  out  all  or  a  portion  of  the 
contents  of  the  gland  into  the  posterior  urethra.  As  soon  as  the 
free  evacuation  of  pus  commences,  the  prostate  may  be  massaged. 
For  this  purpose  it  is  advised  that  the  patient  lie  over  a  chair  or 
table,  that  the  forefinger,  covered  with  a  cot  well  lubricated,  be 
introduced  into  the  rectum,  and  that  the  region  of  the  prostate  be 
manipulated  for  from  one  to  five  minutes.  This  procedure  is 
sometimes  followed  by  a  feeHng  of  great  relief  and  benefit  to  the 
patient,  but  not  infrequently  it  is  painful.  If  conducted  too 
vigorously  in  acute  inflammatory  conditions,  it  increases  the 
activity  of  the  disease,  frequently  giving  rise  to  an  acute  epidid- 
ymitis. In  other  cases  it  may  not  give  rise  to  acute  inflammatory 
disturbances,  but  seems  to  render  the  prostatic  region  sore.  The 
diminution  alone  in  the  size  of  the  prostate,  as  ascertained  bv 
rectal  touch,  may  or  may  not  be  attended  by  improvement  in  the 
general  health  of  the  patient.  Accompanying  diseased  conditions 
of  the  prostate,  a  form  of  hard  edema  may  exist  between  the  gland 
and  the  rectal  walls.  The  disappearance  of  this  edema  as  a  result 
of  massage  does  not  necessarily  indicate  that  the  condition  of  the 
prostate  itself  is  much,  if  at  all,  improved.  Massage  of  the  prostate 
is  seldom  employed  alone  in  the  treatment  of  chronic  prostatitis. 
As  a  rule,  it  is  used  in  conjunction  with  intraurethral  applications 
to  the  prostatic  urethra.  If  its  use,  once  or  twice  a  week,  alone  or 
combined  with  other  measures,  is  followed  by  a  sensation  of 
relief  and  a  feeHng  of  betterment,  and  if  the  'inflammatory  condi- 
tion of  the  prostate  subsides  under  its  use  (indicated  by  a  diminu- 
tion of  the  inflammatory  products  of  the  discharge  that  is  massaged 
into  the  prostatic  urethra  and  passed  out  on  urination),  it  should 
be  continued  for  several  weeks  or  months  at  gradually  increasing 
intervals.     A  study  of  the  pathology  of  the  inflammatory  condi- 


CHRONIC    PROSTATITIS  553 

tions  that  occur  in  the  prostate  helps  to  explain  the  otherwise 
apparently  contradictory  conclusions  often  arrived  at  as  the  result 
of  prostatic  massage.     There  are  three  classes  of  cases : 

1.  In  those  who  suffer  from  pathologic  hypertrophy  of  the 
prostate  massage  is  of  no  benefit,  for  the  reason  that  in  these 
cases  the  mouths  of  the  acini  are  occluded  by  inflammatory  pro- 
ducts, thus  preventing  the  expression  of  the  prostatic  secretion. 
The  aged  generally  make  up  this  class. 

2.  A  mixed  class,  in  some  of  whom  the  orifices  of  the  acini  of 
the  prostate  are  so  occluded  by  inflammatory  products  that  their 
contents  cannot  be  expressed,  while  others  of  the  acini  have 
inflammatory  products  dipping  down  into  them,  the  mouths  of 
the  acini,  however,  being  still  pervious.  Clinically,  in  these 
cases,  as  in  the  previous  class,  it  is  noticed  that  massage  of  the 
prostate  renders  the  prostatic  region  sore,  although,  judging  from 
the  amount  and  character  of  the  secretion  expressed,  it  would  be 
natural  to  presume  that  the  effect  of  the  massage  was  beneficial. 

3.  This  class  consists  of  those  in  whom  the  inflammatory  pro- 
ducts have  dipped  down  into  the  prostatic  acini,  but  enough  scar 
tissue  has  not  as  yet  formed  to  obliterate  the  mouths  of  any  num- 
ber. It  is  among  the  members  of  this  class  that  the  best  results 
from  massage  of  the  prostate  are  observed  to  follow.  A  well- 
known  surgeon  of  Berlin  has  devised  a  method  of  performing 
massage  of  the  prostate  that  apparently  has  much  to  recommend 
it.  It  is  his  custom,  in  cases  of  posterior  urethritis  or  prostatitis, 
to  search  with  his  finger  in  the  rectum  for  a  soft  spot  in  the  pros- 
tate. If  it  is  found,  he  massages  the  rectal  wall  over  the  soft  spot 
with  a  scratching  motion,  leaving  the  remainder  of  the  prostate 
untouched. 

The  writers'  conclusions  concerning  the  use  of  massage  of  the 
prostate  are: 

First :  That  it  should  not  be  attempted  in  every  case  of  chronic 
prostatitis,  but  should  be  tentatively  employed  in  carefully  selected 
cases,  when,  if  apparently  attended  with  good  results,  its  use  should 
be  continued. 

Second:  That  the  examination  of  the  prostate  itself,  by  the 
rectal  touch  alone,  is  not  necessarily  a  satisfactory  guide  as  to 
whether  improvement  has  followed  massage. 


554        DIAGNOSIS    AND   TREATMENT    OF    PROSTATIC    DISEASES 

Third:  That  the  older  the  patient,  the  less  likely  is  prostatic 
massage  to  be  of  benefit. 

Fourth:  That  in  performing  massage  it  is  more  advisable  to 
massage  around  the  prostate  or  over  any  softened  or  boggy  area 
than  to  attempt  manipulations  over  the  entire  surface  of  the  gland. 

General  Treatment. — Neurasthenia  is  so  often  associated  with 
conditions  of  chronic  inflammation  in  the  prostate  that  its  nature 
and  its  effects  on  the  whole  urinary  and  genital  tract  should  be 
better  understood  by  the  surgeon.  Although  neurasthenia  is 
rarely  directly  productive  of  anatomic  diseased  conditions,  a  very 
slight  lesion  of  the  prostatic  urethra  or  the  prostate,  accompanied 
by  general  neurasthenia,  will  be  extremely  difficult  to  cure,  or  to 
materially  benefit  the  prostatic  lesion,  by  even  the  most  skilful 
local  treatment,  unless  the  surgeon  is  also  successful  in  the  treat- 
ment of  the  neurasthenia.  If  the  nervous  condition  is  properly 
treated  and  the  lesion  is  slight,  the  patient  may  be  unaware  that 
any  prostatic  disorder  existed. 

Hypochondriasis  is  a  more  serious  condition,  and  care  should 
be  taken  to  differentiate  it  from  neurasthenia.  It  is  very  often 
associated  with  the  latter,  and  ma}^  become  intensified  as  the 
neurasthenia  improves.  It  may,  of  course,  occur  without  any  ac- 
companying neurasthenia  and  without  the  occurrence  of  any  lesion 
in  the  urethra  or  prostate.  Neurasthenia  is  becoming  recognized 
more  and  more  as  an  entitv  with  a  physical  basis,  and  is  often 
associated  with  anemia  and  lowered  circulation.  In  many  cases 
worry,  mental  or  surgical  shock,  or  an  infectious  disease,  such  as 
malaria,  plays  a  part  in  its  causation.  Hypochondriasis,  however, 
seems  associated  with  a  perverted  mentality,  without  evincing 
any  anatomic  lesion  that  is  at  present  recognizable. 

It  is  well,  therefore,  in  treating  any  lesion  of  the  prostate  or  of 
the  prostatic  urethra,  to  examine  carefully  into  the  general  condi- 
tion of  the  patient,  and  to  improve  any  existing  lowered  condition 
of  circulation  or  nerve  tone.  Life  in  the  open  air,  cold  baths, 
either  plunge  or  sponge-baths,  drip  sheets,  golf,  tennis,  and  above 
all  swimming, — the  latter  exercise  being  a  good  one  for  developing 
the  muscles  of  the  perineum, — are  to  be  recommended  in  suitable 
cases.     An  examination  of  the  blood  is  often  of  value  in  directing 


CHRONIC    PROSTATITIS  555 

the  general  treatment.  If  malarial  plasmodia  are  found  to  be 
present,  quinin  and  arsenic  are  necessary;  or  if  anemia  is  discov- 
ered, the  nonirritating  form  of  iron  salts  may  be  given.  Apart 
from  its  value  as  a  general  tonic,  iron  is  apparently  of  great  service 
for  its  local  action  on  the  neck  of  the  bladder.  It  may  be  given 
as  the  tartrate  of  iron  and  potash  or  combined  with  quinin,  man- 
ganese, nux  vomica,  ignatia,  or  coca.  The  glycerophosphates  of 
calcium  seem  often  to  do  good.  They  should  be  given  in  large 
doses,  continuously,  or  at  intervals  extending  over  a  period  of 
weeks  and  months.  Owing  to  the  intimate  relations  that  exist 
between  the  prostate  and  the  rectum,  care  should  be  exercised 
that  the  bowels  are  kept  freely  open.  It  is  better,  when  possible, 
for  this  purpose  to  rely  on  diet  and  exercise  than  on  powerful 
laxatives.  A  milk  diet  may,  for  a  short  time,  be  advisable  in  cer- 
tain cases,  and  ordinarily,  in  patients  with  prostatic  irritation,  a 
sufficient  but  economic  diet,  consisting  of  a  moderate  amount  of 
meat  and  green  vegetables,  with  milk  in  some  form  at  certain 
'-hours  of  the  day  to  keep  up  the  fat-supply,  is  advisable;  foods 
rich  in  starch  or  sugar  should  be  taken  sparingly.  Strawberries, 
and  particularly  asparagus,  are  known  to  be  irritating  to  the  mu- 
cous membranes  of  the  tract,  and  should  therefore  be  avoided, 
as  should  also  highly  seasoned  articles  of  food.  Alcohol,  unless 
taken  in  very  small  quantities  well  diluted,  is  not  advisable.  Red 
wines  are  generally  too  acid,  the  light  white  French  wines,  which 
are  not  sweet,  and  the  light  Moselle  wines,  diluted  with  water, 
are  less  harmful.  The  various  carbonic  waters,  such  as  artifi- 
cial Vichy,  now  so  freely  used,  frequently  tend  to  aggravate  or 
may  even  provoke  irritation  of  the  neck  of  the  bladder  if  indulged 
in  excessively. 

Of  the  resinous  substances  having  a  direct  effect  on  the  mucous 
membrane  of  the  neck  of  the  bladder,  tending  to  allay  irritation, 
kava-kava  is  among  the  best.  Dram  doses  of  the  fluidextract 
of  kava-kava  well  diluted  in  water,  and  given  three  or  four  times 
a  day,  are  often  of  benefit  if  tolerated  by  the  stomach.  If  the 
urine  is  scanty,  with  a  high  specific  gravity,  spiritus  getheris  nitrosi 
in  half-dram  doses  several  times  daily  is  of  benefit,  and  salol  and 
urotropin  are  often  useful.     They  are  well  borne  when  combined 


556         DIAGNOSIS    AND    TREATMENT    OF    PROSTATIC    DISEASES 

in  the  same  capsule.  Sandalwood  oil,  alone  or  with  kava-kava, 
or  powdered  cubebs  with  sodium  bicarbonate,  sometimes  has  a 
soothing  effect.  Dram  doses  of  the  latter  stirred  up  in  water  are 
well  borne  by  the  stomach  and  are  occasionally  of  benefit.  When 
there  is  marked  ner\^ous  irritability,  with  frequent  micturition, 
but  no  lesion  of  any  magnitude,  tincture  of  cantharides,  in  one- 
drop  doses  administered  several  times  a  day,  may  be  used  with 
advantage.  For  the  relief  of  pain  tincture  of  hyoscyamus  or 
suppositories  containing  opium  or  belladonna  are  occasionally 
required,  and  suppositories  of  ichthyol  may  sometimes  act  well  in 
helping  to  overcome  congestion.  It  has  been  the  custom,  in  the 
past  few  years,  to  recommend  hot  rectal  irrigations  for  the  relief 
of  inflammatory^  conditions  at  the  neck  of  the  bladder,  and  a  great 
many  different  apparatus  for  carrying  out  this  treatment  have 
been  invented;  the  writers  have  found,  however,  that  as  good 
results  can  be  attained  otherwise,  with  less  trouble  and  annoyance 
to  the  patient.  Apparatus  for  applying  cold  to  the  rectum  have 
also  been  devised,  but  have  never  come  into  general  use,  nor  do^ 
we  recommend  them. 

In  our  e  :cperience  extensive  operative  procedures,  except  for 
abscess  of  the  prostate  of  some  considerable  size,  reference  to 
which  will  be  made  in  the  following  article,  are  unnecessary  for 
the  treatment  of  this  condition.  That  such  operation  can  be  per- 
formed as  partial  prostatectomy  without  serious  after-results,  and 
that  in  certain  cases  improvement  in  the  general  condition  of  the 
patient  may  follow,  is  not  disputed,  but  our  experience  along 
two  different  lines  has  led  us  to  the  conclusion  expressed  above. 
Working  along  one  of  these  lines  of  investigation  we  find  if 
these  patients  can  be  kept  under  observation,  the  deep  urethra 
dilated  with  a  Kollmann  dilator,  irrigations  of  nitrate  of  silver, 
which  are  not  strong,  used  once  or  twice  weekly,  and  the  general 
tone  of  the  patients  improved  through  proper  hygienic  mea- 
sures, unless  tuberculosis  or  some  other  intercurrent  disease  is 
present,  such  patients  improve  rapidly  and  permanently.  It  is 
in  just  such  cases  that  massage  of  the  prostate  seems  often  to 
be  overdone,  and  not  infrequently  patients  are  found  who  have 
also  been    overtreated    in  other  respects.      The  other  factor  to 


ABSCESS  OF  THE  PROSTATE  557 

which  we  wish  to  call  attention  is  that  of  time.  Patients  are 
occasionally  seen  by  us  who  have  had  marked  prostatitis  many 
years  previously,  who  have  come  under  observation,  improved 
somewhat  under  treatment,  disappeared  from  view,  and  after  sev- 
eral years'  absence  reappeared  to  be  treated  for  some  other  con- 
dition, give  a  history  of  having  had  no  treatment  during  the 
interval,  and  in  whom  the  prostate  has  been  found  to  be  in  a 
healthy  condition. 

ABSCESS  OF  THE  PROSTATE 

Various  forms  of  abscess  of  the  prostate  may  be  seen  cHnically, 
but  the  pathologic  anatomy  of  all  is  very  similar.  It  is  only  the 
large  abscesses  that  give  rise  to  serious  disturbances.  They  occur 
at  any  age,  and  are  occasionally  of  tuberculous  origin.  The  most 
common  form  is  that  which  accompanies  or  follows  an  attack  of 
acute  urethritis.  In  a  large  majority  of  cases  the  abscess,  if 
allowed  to  run  its  course,  will  burst  into  the  floor  of  the  prostatic 
urethra,  as  described  in  a  previous  chapter;  when  this  occurs, 
healing  may  follow,  or  as  more  frequently  happens,  a  chronic 
prostatitis  may  be  set  up.  Clinically,  an  abscess  presents  all  the 
symptoms  of  an  intense  posterior  urethritis,  the  prostate  being 
sometimes  enormously  swollen  and  tender  to  the  touch.  Very 
often  a  soft  spot  or  a  dimple-like  depression  can  be  felt  upon  its 
surface. 

It  is  best  treated  by  rest  in  bed,  the  internal  administration 
of  urinary  antiseptics,  sedatives  and  opium,  if  necessary,  in 
sufhcient  quantities  to  relieve  pain.  Such  patients  usually  com- 
plain of  a  sensation  as  if  a  cannon  ball  were  suspended  between 
their  legs.  If  the  abscess  does  not  open  into  the  floor  of  the 
urethra,  it  may  burst  into  the  rectum  or  through  the  perineum. 
In  doubtful  cases  it  is  best  to  watch  the  development  and  course 
of  the  abscess  for  some  time  before  proceeding  surgicallv.  If 
the  symptoms  become  worse,  the  patient  losing  weight  and 
strength,  with  indications  of  the  onset  of  septicemia,  and  if  the 
abscess  displays  no  tendency  to  open  into  the  urethra,  operative 
procedures  for  its  relief  must  be  considered. 

A  prostatic  abscess  may  be  opened  from  within  the  urethra, 
by  the  method  the  writers  prefer  for  the  treatment  of  hypertrophy. 


558        DIAGNOSIS    AND   TREATMENT    OF    PROSTATIC    DISEASES 

1.  e.,  the  Bryson  method,  which  is  fully  described  elsewhere; 
or  it  may  be  opened  by  way  of  the  perineum.  At  times  a  simple 
semilunar  incision  is  all  that  will  be  required,  as  the  swollen 
prostate  may  bulge  toward  the  perineum.  The  prostate  being 
exposed  through  one  of  the  incisions  named  in  the  previous  chapter, 
a  knife  should  be  pushed  into  the  bulging  portion,  the  pus  evacu- 
ated, the  cavity  washed  out,  and  drainage  instituted  for  a  few  days. 
Opening  the  prostate  through  the  rectum  for  the  rehef  of  abscess,  so 
frequently  recommended  in  the  earher  text-books  on  surgery,  is 
a  bad  procedure  and  should  not  be  resorted  to. 


Fig.  262. —  Microphotograph  showing  corpora  amylacea  in  abscess  of  the  prostate. 

A  good  plan,  before  performing  any  serious  operation  on  the 
prostate,  is  to  massage  the  gland  carefully,  with  a  finger  in  the 
rectum,  and  see  if  pus  can  be  expressed.  The  writers  have  seen 
cases  of  prostatic  abscess  of  considerable  size,  in  which,  as  a 
result  of  this  massage,  large  quantities  of  pus  were  expressed, 
the  volume  of  the  prostate,  as  felt  by  the  examining  finger  in  the 
rectum,  being  immediately  greatly  reduced  and  a  favorable  course 
followed. 

Occasionally  an  abscess  is  found  associated  with,  or  simulating, 
the  prostatic  hypertrophy  of  the  aged;  small  prostatic  abscesses 
are  also  often  a  part  of  or  associated  with  posterior  urethritis. 


PROSTATIC   CALCULI  559 

In  these  cases,  massage  of  the  prostate,  if  skihuhy  performed,  fol- 
lowed by  irrigations  with  weak  silver  nitrate  solution  (i  :  10,000), 
may  be  of  benefit.  This  treatment  should  be  repeated  at  inter- 
vals of  from  two  days  to  a  week,  and  should  cover  a  period  of 
several  months;  later  the  posterior  urethra  should  be  carefully 
dilated  by  means  of  a  Kollmann  dilator.  Attention  should  also 
be  directed  toward  improving  the  health  and  strength  of  the 
patient.  The  pus  should  be  examined  for  tubercle  bacilli.  In 
large  prostatic  abscesses  of  tuberculous  origin,  the  surgical  treat- 
ment is  that  of  abscesses  due  to  other  causes.  When  the  presence 
of  tubercle  bacilli  has  been  demonstrated,  the  patient  should  be 
placed  amid  the  most  favorable  hygienic  surroundings.  In  these 
cases  not  much  is  to  be  expected  from  local  measures.  Irriga- 
tions of  mercury  cyanid  may  be  tried,  or  instillations  of  gomerol 
mav  be  used.     Silver  nitrate  will  be  found  to  be  too  irritating. 

Abscesses  of  the  prostate  have  been  reported  following  carbuncle 
on  the  neck  in  patients  who  had  never  had  gonorrhea.  They 
have  been  reported  as  causing  edema  of  a  septic  nature  in  the 
cavity  of  Retzius.  They  may  follow  pyemia  or  the  grip.  ]Mr. 
Harmonic^  considers  diabetics  are  particularly  liable  to  have 
abscess  of  the  prostate.  Mr.  Minet,  at  the  same  meeting,  con- 
sidered the  question  of  periprostatic  abscesses,  and  found  them 
most  often  retroprostatic,  retrovesical,  or  lateroprostatic.  We  have 
recently  operated  on  one  case  of  this  description,  apparently  of 
gonorrheal  origin.  '  It  has  been  thought  by  some  that  these  pros- 
tatic abscesses  might  remain  latent  for  a  number  of  years  and 
then  show  themselves.  This  view  is  probably  true  to  some  extent, 
but  the  anatomic  investigations  which  have  been  carried  on  by 
us,  and  to  which  reference  is  made  earlier  in  the  chapter,  tend  to 
show,  if  abscesses  of  the  prostate  are  not  so  extensive  as  to  give 
rise  to  sepsis  and  demand  immediate  operation,  in  the  course  of 
time  the  cavities  become  filled  with  cicatricial  tissue. 

PROSTATIC  CALCULI 

Generally  speaking,  two  varieties  of  prostatic  calcuH  may  be 
said  to  occur :  one  variety,  that  almost  invariably  comes  from  a 
focus  in   the  bladder,  becoming  later   attached  to  the   walls   of 
^  "  Eleventh  Session  Assoc.  FranQaise  Urology." 


560        DIAGNOSIS    AND    TREATMENT   OF    PROSTATIC    DISEASES 

the  prostatic  urethra,  and  surrounded  by  urinary  sahs,  gener- 
ally phosphatic  in  character.  These  are,  to  be  accurate,  urethral 
rather  than  prostatic  calculi.  In  the  other  form  the  stones  are 
formed  as  the  result  of  obliteration  of  the  mouths  of  the  acini  and 
the  calcification  of  their  retained  exudate.  They  are  generally 
found  in  elderly  persons.  If  they  give  rise  to  symptoms  of  distress 
and  inconvenience,  they  may  be  removed  by  making  a  perineal 
incision  and  digging  them  out  from  the  prostatic  urethra,  in  a 
manner  similar  to  that  by  which  the  large  lateral  lobes  are  re- 
moved, A  third  variety  of  prostatic  calculi  are  occasionally  seen ; 
these  are  phosphatic  in  character,  extremely  minute,  and  resemble 
somewhat  the  scales  of  a  very  small  fish.  They  are  to  be  found 
lining  the  posterior  urethra  and  dipping  down  into  the  prostatic 
"follicles.  When  necessary  they  may  be  removed  through  the  or- 
dinary perineal  incision,  such  as  would  be  made  for  a  tight  stric- 
ture. Clinically,  their  presence  may  be  discovered  upon  examining 
the  urine,  or  on  their  striking  the  end  of  some  instrument,  such  as 
the  Thompson  searcher ;  or  they  may  be  observed  under  the  endo- 
scope. The  same  methods  will  serve  to  show  the  presence  of  the 
impacted  larger  prostatic  urethral  calcuH,  first  mentioned,  whereas 
the  true  prostatic  calculi  forming  in  the  body  of  the  prostate  can 
sometimes  be  diagnosed  by  making  a  rectal  examination  at  the 
same  time  that  the  instrument  is  introduced  into  the  bladder. 
Occasionally,  gravel  passing  out  of  the  bladder  into  the  prostatic 
urethra  on  its  way  down  from  the  kidney  will  give  rise  to  pain  and 
distress,  causing  a  spasm  of  the  prostatic  urethra  which  may  be  so 
severe  as  to  provoke  hemorrhage.  For  the  rehef  of  the  spasm  the 
patient  should  be  ordered  to  urinate  while  lying  in  a  warm  bath; 
large  quantities  of  fluid  should  be  drunk,  and  hyoscyamus,  kava- 
kava,  and  perhaps  glycerin  in  large  doses,  administered. 

PROSTATIC  HYPERTROPHY 
Diagnosis.— As  has  been  pointed  out,  prostatic  hypertrophy,  ana- 
tomically speaking,  instead  of  being  confined  to  the  aged,  as  is  com- 
monly believed,  may  occur  in  comparative  youth,  provided  severe 
inflammatory  processes  have  previously  existed  in  the  prostatic 
urethra.  If  this  enlargement  is  extensive  enough,  it  will  interfere 
somewhat  with  the  complete  emptying  of  the  bladder.     Prostatic 


PROSTATIC   HYPERTROPHY  561 

enlargement  of  so  severe  a  degree  may  exist  that,  after  urination, 
several  ounces  of  urine  may  be  retained,  without  giving  rise  to 
cHnical  symptoms  of  any  importance  if  the  urine  does  not  become 
infected,  and  if  the  patient  does  not  become  exhausted  as  the 
result  of  intercurrent  disease.  If  the  bladder  muscle  and  the 
fibers  surrounding  the  neck  of  the  bladder  and  the  prostate  are 
weakened  because  of  some  systemic  disorder,  then  prostatic 
obstruction  may  cause  retention.  If  acute  inflammation  attacks 
the  base  and  neck  of  the  bladder  as  the  result  of  infection, 
as  from  gonorrhea  or  following  the  passage  of  an  unclean  instru- 
ment, an  enlargement  of  the  prostate  tends  to  retard  recovery 
from  such  inflammation.  Such  cases  are  frequently  encountered, 
very  often  presenting  no  marked  clinical  symptoms  except  a 
slight  chronic  posterior  urethritis  that  does  not  yield  readily  to 
treatment,  and  the  presence  of  residual  urine  varying  in  amount 
from  one  to  eight  ounces.  It  is  sometimes  difficult,  in  these 
cases,  to  determine  what  form  of  prostatic  enlargement  is  present — - 
whether  of  the  lateral  lobes,  the  third  lobe,  or  of  both.  In  most 
enlargements,  however,  the  two  side  lobes  are  involved  to  a  greater 
or  less  extent.  The  form  of  prostatic  enlargement  may  be  deter- 
mined, or  diagnosis  aided,  by  introducing  a  catheter  into  the 
bladder  and  passing  it  back  to  the  posterior  surface  of  the  viscus. 
All  the  urine  in  the  bladder,  or  the  residual  urine,  if  the  patient 
has  urinated,  should  be  allowed  to  run  out  through  the  catheter, 
which  should  then  be  withdrawn  very  slowly.  After  one  or  two 
inches  of  the  catheter  have  been  returned,  more  urine — from  2 
drams  to  4  ounces — may  flow  out  of  the  end  of  the  instrument, 
tending  to  show  the  presence  of  a  pocket  in  the  bladder,  often 
due  to  a  third  lobe  enlargement.  On  withdrawing  the  catheter 
still  farther,  only  a  few  drops — a  half  dram  or  so — of  urine  that 
may  have  remained  within  the  urethra  will  escape.  In  examin- 
ing a  patient,  with  chronic  retention,  if  a  large  amount — -over 
eight  ounces — of  residual  urine  is  found,  the  bladder  should  not 
be  emptied  completely  at  the  first  examination,  unless  some  other 
fluid  is  injected  in  place  of  the  urine,  as  the  too  sudden  empty- 
ing of  an  overdistended  bladder  may  give  rise  to  cystitis,  hemor- 
rhage, or  shock. 

The  diagnosis  may  sometimes  be  made  by  passing  a  Kollmann 
36 


562        DIAGNOSIS    AND    TREATMENT   OF   PROSTATIC    DISEASES 

dilator  into  the  bladder  and  screwing  it  up  about  No.  30.  A 
contraction  will  be  felt,  offering  a  very  strong  resistance  to  any- 
further  distention  of  the  neck  of  the  bladder  by  the  dilator.  It 
is  often  possible,  in  these  cases,  to  dilate  to  within  one  number 
of  the  point  at  which  the  contraction  is  felt  without  producing 
discomfort,  and  without  any  marked  difference  being  noticed 
as  regards  obstruction  to  the  distention  of  the  instrument  up 
to  that  point.  At  that  particular  point  and  beyond  strong  re- 
sistance is  met.  Ordinarily  this  is  evidence  either  of  stricture 
at  the  bulbomembranous  junction  or  of  the  results  of  inflamma- 
tory conditions  deeper  in  toward  the  neck  of  the  bladder,  condi- 
tions not  infrequently  found  associated  with  prostatic  hypertrophy. 
In  healthy  urethras  No.  40  can  often  be  reached  on  the  scale  of 
the  dilator  without  contraction  becoming  apparent.  A  searcher 
may  be  passed,  rotated  to  one  side  and  withdrawn  until  it  is  caught, 
then  rotated  to  the  other  side  of  the  bladder,  and  the  same  pro- 
cedure gone  through,  any  difference  to  the  extent  it  can  be  with- 
drawn being  noticed  on  the  marker  on  the  searcher,  also  completely 
rotated  and  then  brought  forward.  B}^  this  means  the  approxi- 
mate size  of  the  prostate  may  be  arrived  at.  It  should  also  be 
examined  with  a  searcher  or  sound  in  the  bladder  and  a  finger 
in  the  rectum,  and,  finally,  in  a  doubtful  case,  the  view  obtained 
through  the  cystoscope  will  be  of  great  diagnostic  aid  to  the  com- 
petent observer. 

In  making  a  diagnosis  of  prostatic  hypertrophy  care  must  be 
taken  not  to  confound  the  difficulty  in  micturition  due  to  this 
condition  or  to  stricture  with  that  due  to  diseases  of  the  nervous 
system  or  of  the  kidney,  or  to  simple  muscular  weakness  due 
to  age  or  exhausting  disease  of  the  bladder-wall.  Ciechanowski 
has  found,  by  making  careful  measurements  of  the  bladder  mus- 
cular tissue,  comparing  the  bladder-walls  of  the  aged  and  of  the 
young,  that  there  is  likely  to  be  a  diminution — a  very  large  one, 
of  some  50  per  cent,  or  more — in  the  amount  of  muscular  tissue 
of  the  bladder- wall  of  the  aged,  even  when  no  acute  inflammatory 
condition  of  the  bladder-wall  exists. 

Symptoms. — The  clinical  symptoms  of  prostatic  hypertrophy 
have  been  previously  mentioned  and  are  generally  well  understood. 
The    most    prominent    are    increased    frequency   in    micturition, 


PLATE  XVI 


Hypertrophy  of  the  lateral  lobes  of  the  prostate  -\vith  the  tumor  presenting 
inside  the  bladder  and  showing  an  oval  calculus  lodged  in  a  sacculation  pos- 
terior to  the  enlarged  prostate.  (From  a  specimen  in  the  Carnegie  Laboratory 
Museum.)  (Natural  size.)  a,  Thickened  and  inflamed  folds  of  the  bladder 
mucosa ;  h,  calculus  lodged  in  sacculation  of  the  bladder  wall ;  c,  enlarged 
lateral  lobes  of  prostate ;  d,  root  of  the  penis  showing  slight  degree  of  enlarge- 
ment of  prostate  outside  of  bladder. 


PROSTATIC  HYPERTROPHY  563 

with  apparent  loss  of  muscular  power  to  perform  the  act,  the 
increase  being  most  noticeable  at  night  or  toward  early  morning ; 
diminution  in  the  size  of  the  stream,  and,  following  attacks  of 
cold  or  of  dissipation,  very  probably  a  history  of  retention. 

In  those  cases  presenting  the  clinical  appearance  of  chronic 
posterior  urethritis,  together  with  a  resistance  to  a  Kollmann 
dilator  in  the  prostatic  urethra  at  about  No.  30  French,  associated 
with  retention  of  urine— from  4  to  8  ounces — and  proving  rebel- 
lious to  the  simple  treatment  of  posterior  urethritis — that  is,  not 
showing  a  marked  tendency  to  get  well  under  hygienic  treatment, 
as  ordinary  cases  of  posterior  urethritis  often  do — we  may  be  quite 
sure  that  we  are  dealing  with  prostatic  hypertrophy.  The  cases 
of  so-called  chronic  contraction  of  the  bladder  neck,  as  described 
by  some  specialists,  are  to  be  found  in  this  class.  There  is  no 
reason  why,  anatomicallv,  there  should  not  be  chronic  contraction 
of  the  bladder  neck.  The  old  belief  that  stricture,  meaning  b}'' 
that  the  formation  of  scar  tissue,  could  not  exist  in  the  prostatic 
urethra  was  found  to  have  no  anatomic  foundation.  The  scar 
tissue  forming  in  the  deep  urethra  may  give  rise  to  the  so-called' 
third  lobe  enlargement  or  enlargement  of  the  lateral  lobes  of  the 
prostate  in  the  manner  already  described.  It  may  also,  through 
infiltrating  into  the  surrounding  tissue,  cause  bands  of  cicatricial 
tissue  to  form  in  the  prostatic  urethra.  Bands  do  occasionally 
exist,  but  are  of  comparatively  rare  occurrence.  The  writers 
believe  that  these  cases,  which  have  been  considered  by  some 
observers  under  the  heads  of  chronic  contraction  of  the  bladder 
neck,  are  due  chiefly  to  third  lobe  prostatic  enlargement;  but 
whether  due  to  this  or  to  infiltration  of  scar  tissue  in  the  prostatic 
urethra,  the  writers  have  never  seen  any  uncomplicated  case  that 
needed  operative  treatment  for  its  reUef ,  beyond  such  as  might  be 
furnished  by  dilatation  with  the  Kollmann  dilator  and  treatment 
of  any  accompanying  posterior  urethritis. 

Treatment. — Dilatation  of  the  prostatic  urethra  at  intervals  of 
a  week  or  two  weeks,  carefully  performed  by  means  of  the  Koll- 
mann dilator,  together  with  or  alternating  with  solutions  of  silver 
nitrate  of  varying  amount  and  strength,  and  proper  constitutional 
treatment,  will  benefit  very  markedly  those  cases  of  contraction 
at  the  neck  of  the  bladder  for  which  no  radical  operation  is  re- 


564       DIAGNOSIS    AND   TREATMENT   OF    PROSTATIC    DISEASES 

quired.  These  same  measures  are  the  ones  to  be  adopted  in 
almost  any  case  of  prostatic  hypertrophy,  in  the  hope  that, 
through  distention  of  any  cicatricial  tissue,  some  of  the  acini 
may  be  opened,  and  the  neck  of  the  bladder  toned  up  to  the 
point  of  recovering  its  energy  and  properly  performing  its  func- 
tions. Sounds  should  not  be  used,  as  their  introduction  injures 
the  prostate.  Irrigations  of  weak  solutions  of  silver  nitrate 
(i :  10,000)  ordinarily  give  the  best  results.  Great  care  and  gentle- 
ness should  be  used  in  the  introduction  of  the  Kollmann  dilator. 
At  first  the  instrument  should  not  be  distended  to  more  than 
No.  30  to  32,  at  which  point  generally  considerable  resistance 
will  be  met  with.  At  each  application  it  should  ordinarily  be 
distended  one  or  two  points  more,  until  a  distention  of  from  No. 
40  to  44  can  be  obtained.  It  should  be  allowed  to  remain  in 
the  bladder  for  not  more  than  one  to  three  minutes  on  each 
introduction. 

If  treatment  along  the  lines  indicated  fail,  after  it  has  been 
thoroughly  tested  over  a  period  of  weeks  or  months,  and  the  dis- 
turbances incident  to  the  prostatic  hypertrophy  increase,  as  shown 
by  a  more  frequent  demand  for  the  use  of  the  catheter  on  account 
of  complete  or  partial  retention,  two  modes  of  procedure  are  open 
to  the  patient.  One  is  to  adopt  the  so-called  catheter  life,  and  the 
other  is  to  undergo  a  radical  operation  for  the  relief  of  the  prostatic 
obstruction.  So  much  has  been  written  concerning  catheter  life 
that  nothing  remains  to  be  said.  Fortunately,  in  our  experience 
the  members  of  this  class  are  growing  fewer  in  numbers  and  more 
and  more  often  do  we  find  them  at  least  greatly  improving  under 
appropriate  local  and  general  treatment,  but  some  few  exist. 
The  surgeon,  some  member  of  the  patient's  family,  and,  later 
on,  when  possible,  the  patient  himself,  may  draw  the  urine  by 
means  of  a  soft-rubber,  velvet-eyed  catheter  of  the  smallest 
size  that  will  empty  the  bladder  without  consuming  much 
time.  If  the  velvet-eyed  soft  catheter  is  introduced  with  dif- 
ficulty, the  Mercier  or  a  bicoude  may  be  used  instead.  Before 
using,  the  catheter  should  be  carefully  sterilized  by  immersing  it 
in  boiling  water.  Sterilized  white  vaselin,  which  is  sold  in  small 
tubes,  makes  the  best  lubricant  for  these  cases.  The  frequency 
with  which  the  catheter  must  be  used  will  depend  upon  the  indi- 


PLATE  XVII 


Senile  hypertrophy  of  the  prostate,  showing  resulting  tortuous  stricture 
of  the  posterior  urethra  and  atrophy  of  the  bladder.  (From  a  specimen 
in  the  Carnegie  Laboratory  Museum.)  (Natural  size.)  a,  Atrophied  bladder 
showing  hypertrophy  of  therugse;  b,  urethra;  c,  encapsulated  "adenomatous" 
nodules  of  enlarged  prostate. 


PROSTATIC    HYPERTROPHY  565 

vidual  case.  Early  in  the  history  of  their  catheter  Ufe  patients 
may  be  able  to  use  the  catheter  three  times  a  week ;  the  intervals 
are  gradually  shortened  until  it  is  used  daily,  and  then  every  six 
to  eight  hours.  It  was  generally  believed,  in  the  past,  that, 
after  emptying  the  bladder,  it  was  a  good  plan  twice  a  day,  daily, 
or  two  or  three  times  weekly,  to  wash  out  the  organ.  In  certain 
cases,  probably,  the  bladder  is  washed  out  too  often.  Each  case 
should  be  a  law  unto  itself.  Of  the  solution  to  be  used  for  bladder 
lavage,  boric  acid  is  probably  to  be  preferred;  in  some  cases  listerine, 
well  diluted,  or  salt  and  water  may  be  used ;  ordinarily  unirritat- 
ing  and  unstimulating  preparations  give  the  best  results.  Oxy- 
cyanid  of  mercury  i  :  5000  may  be  tried.  If  the  patient  does  not 
do  well  on  the  catheter  life,  a  radical  operation  for  the  cure  of  the 
prostatic  enlargement  may  be  attempted.  Beyond  the  discom- 
fort and  annoyance  incident  to  the  use  of  the  catheter,  patients 
may  continue  its  use  for  years  without  manifesting  any  serious 
disturbance.  One  patient  under  the  writers'  observation  has 
been  obUged  to  use  the  catheter  for  twenty-five  years.  In  many 
cases,  on  the  other  hand,  the  adoption  of  catheter  life  seems  to  be 
the  beginning  of  the  end.  Within  a  few  months  or  a  few  years 
recurrent  attacks  of  cystitis,  associated  often  with  pyelonephritis, 
occur,  and  a  general  septic  condition,  followed  by  death,  ensues. 
What  relief,  then,  can  conscientiously  be  offered  any  prostatic 
case  that  has  reached  a  point  at  which  the  posterior  urethra  will 
no  longer  react  to  stimulating  measures,  such  as  dilation  or  irri- 
gations, and  where  the  neck  of  the  bladder  cannot  be  made  to 
recover  its  tone? 

The  death-rate  following  operation  for  the  relief  of  a  prostatic 
enlargement  is  comparatively  small.  In  well-selected  cases  it 
should  not,  if  properly  performed  by  one  of  the  methods  advised, 
be  above  5  per  cent.  In  a  series  of  operations  that  may  be 
called  emergency  operations,  which  must  be  performed  for  the 
immediate  relief  of  a  patient  suffering  from  prolonged  retention, 
and  in  which  a  general  septic  condition  is  present,  the  death-rate 
will  naturally  be  higher,  a  fact  that  should  not  be  set  down  as 
due  to  the  operation.  The  writers  are  incHned  to  recommend 
emergency  operations — that  is,  if  a  patient  with  retention  due 
to  prostatic  hypertrophy  is  in  such  a  condition  that  a  perineal 


566       DIAGNOSIS    AND    TREATMENT    OF    PROSTATIC    DISEASES 

section  or  a  suprapubic  cystotomy  is  required  for  the  relief  of  the 
condition,  they  consider  it  good  surgery  ordinarily  to  remove  the 
prostate  at  the  same  time,  through  the  same  opening,  by  one  of 
the  methods  about  to  be  described. 

\\'Tiat  can  be  promised  in  regard  to  improvement  in  selected 
cases  if  recovery  from  prostatectomy  ensues?  In  performing  a 
radical  operation  on  a  man  who  has  a  distended  bladder  and  is 
obliged  to  depend  upon  the  catheter,  who  has  had  chronic  cystitis 
for  manv  years,  with  a  thickening  of  the  bladder-walls  and  incon- 
tinence of  urine  due  to  the  cystitis,  a  certain  amount  of  relief 
can  be  promised  and  the  dangers  of  sepsis  lessened.  It  cannot 
be  promised,  however,  that  the  bladder-walls  will  lose  their  thick- 
ening, that  the  mucous  membrane  of  the  bladder  will  become  the 
same  as  that  of  a  young  man,  that  the  muscles  of  the  neck 
will  soon  recover  their  tone,  or  that  a  man  who  has  been  unable 
to  control  the  act  of  urination  for  a  long  time  will  recover  that 
power  and  never  again  exhibit  residual  urine.  A  well-selected 
case,  receiving  proper  after-treatment,  will  probably  be  benefited, 
so  that  the  patient's  condition,  say  three  months  from  the  date 
of  the  operation,  will  be  better  than  it  would  have  been  if  the 
operation  had  not  been  performed.  To  a  man  about  to  begin 
the  catheter  life,  who  still  has  some  control  over  the  muscles 
at  the  neck  of  the  bladder,  who  is  not  entirely  dependent  upon 
the  catheter,  although  he  may  have  had  a  few  attacks  of 
retention,  more  hope  of  relief  can  be  promised,  or  at  least  ex- 
pected. The  muscles  may  so  recover  their  tone  that  he  will 
not  be  subject  to  retention,  and  he  may  be  able  to  empty  his 
bladder,  the  danger  of  sepsis  will  be  averted,  his  condition  be 
rendered  more  comfortable,  and  the  catheter  life  may  be  entirely 
avoided  or  postponed  and  life  prolonged.  As  regards  the  sexual 
function,  if  it  is  not  already  gone,  it  is  likely  to  become  lost, 
although  not  necessarily,  as  a  result  of  the  operation.  This 
should  be  clearly  stated  to  the  patient  before  operating  either  in 
emergency  or  in  selected  cases.  There  is  some  slight  danger, 
apart  from  the  danger  of  death  immediately  following  the  opera- 
tion, of  a  rectal  or  suprapubic  fistula  being  left  behind,  and  recur- 
ring unpleasant  attacks  of  relapsing  orchitis  or  epididymitis  are 
quite  likely  to  follow. 


PROSTATIC  HYPERTROPHY 


567 


Our  greater  personal  experience  obtained  since  the  earlier  edi- 
tions of  this  work  have  cleared  our  ideas  as  to  what  should  be 
done  for  the  relief  of  an  individual  suffering  from  an  enlargement 
of  the  prostate.  Each  case  to  a  greater  or  less  extent  has  to  be 
considered  on  its  own  merits,  outside  surroundings  modifying 
to  a  degree  the  treatment  that  should  be  instituted.  We  beheve 
that  the  class  of  men  at  present  leading  the  catheter  life  will 
gradually  grow  smaller  and  smaller,  not  necessarily,  however, 
from  an  increased  number  of  operations  for  the  removal  of  the 
entire  prostate,  and  we  believe  that  to  some  degree  the  lives 
of  the  individuals  at  present  requiring  a  so-called  emergency 
operation  will  be  prolonged  from  a  better  understanding  of  meth- 
ods of  treatment  previous  to  the  operation,  clearer  ideas  as  to  the 
amount  of  the  prostate  to  be  removed  at  the  operation,  and  a  bet- 
ter understanding  of  the  proper  after-treatment.  The  question  of 
drainage  being  one  of  the  most  important  factors,  when  properly 
understood,  that  will  aid  in  reducing  the  mortality  among  these 
people.  We  frequently  have  under  our  care  individuals  with 
from  4  ounces  to  i  pint  of  residual  urine,  with  a  history  of  from 
one  to  three  attacks  of  complete  retention,  who,  under  the  proper 
general  and  local  measures  previously  mentioned  become  able 
to  entirely  empty  their  bladders,  and  who  become,  as  far  as  symp- 
toms are  concerned,  entirely  well,  the  frequency  of  urination  at 
night  becoming  normal.  The  above  represents  the  class  of  cases 
from  which  the  ranks  of  those  who  lead  a  catheter  life  have  in  the 
past  been  recruited,  and  who  are  at  present  frequently  subject 
to  operation  for  the  entire  removal  of  the  prostate,  and  who  are 
not,  even  when  the  operation  is  most  skilfully  performed,  con- 
stitutionally eventually  benefited  by  such  operation.  In  our 
observation,  even  if  it  relieves  their  difficulty  in  micturition, 
it  seems  in  some  way  to  sap  their  nervous  force,  and  if  such  an 
expression  is  excusable,  take  the  "steel  from  their  blood."  The 
class  of  patients  is  more  rarely  seen  in  which  such  a  condition  as 
recurring  hemorrhage  necessitates  the  removal  of  their  enlarged 
prostate.  In  our  observation  where  malignancy  is  not  present 
this  is  generally  found  among  those  far  advanced  in  years.  Re- 
moval of  their  prostate,  provided  they  recover  from  the  shock  of 
the  operation,  tends  to  prolong  their  life  and  render  them  com- 


568        DIAGNOSIS   AND   TREATMENT   OF    PROSTATIC    DISEASES 

paratively  comfortable.  The  second  class  which  requires  opera- 
tion is  the  class  in  which  the  so-called  emergency  operation  has  to 
be  performed.  This  class  is  more  often  met  with  in  hospitals, 
but  is  occasionally  seen  in  private  practice.  The  prostatic  hyper- 
trophy in  these  individuals  has  become  so  marked  as  to  render 
their  prostates  enormous  in  size,  and  they  may  project  in  varying 
shapes  into  the  bladder;  associated  with  these  is  generally  a  large 
amount  of  residual  urine.  We  have  had  several  cases  come  under 
our  care  recently  in  which  2  quarts  were  present;  these  individuals 
have  nephritis  and  often  hydro-  or  pyonephrosis.  They  require 
drainage,  and  frequently  the  removal  of  the  obstruction  either  at 
once  or  by  a  two-stage  operation.  Operative  procedures  in  such 
individuals  generally  for  the  removal  of  all  or  part  of  the  prostate 
tends  to  prolong  their  existence.  The  prognosis  should  be  guarded, 
as  these  patients,  whether  they  are  operated  upon  or  not,  are  apt 
to  live  but  a  short  time. 

Operation. — Only  two  methods  of  relief  by  operation  on  the 
prostate  will  be  here  considered  in  detail:  the  intra-urethral  and 
the  suprapubic.  In  addition  to  these  two  methods  of  removing 
the  prostate,  a  general  method  of  operating  has  been  described, 
by  means  of  which,  through  a  perineal  incision,  the  rectum  may 
be  separated  from  the  urethra,  prostate,  and  seminal  vesicles, 
making  a  road  by  which  any  of  these  organs  may  be  reached. 
Removal  of  the  prostate  from  without  the  capsule,  though  not 
recommended,  may  be  effected  in  this  way. 

For  the  operative  work  on  the  prostate  in  this  country  great 
credit  is  due  to  John  P.  Bryson,  of  St.  Louis,  and  to  Samuel  Alex- 
ander, of  New  York.  Dr.  Bryson,  about  two  years  before  his 
death,  wrote  a  paper  describing  certain  methods  of  operating  on 
the  prostate;  in  this  he  stated  that  at  that  time  he  had  operated 
on  116  cases.  So  far  as  can  be  determined,  the  methods  employed 
by  these  two  operators  are  very  similar,  if  not  identical.  The 
procedure  consists  of  digging  out  the  lateral  lobes  and  the  third 
lobe  of  the  prostate  with  a  finger  inside  the  prostatic  urethra 
through  an  incision  such  as  is  ordinarily  made  in  the  perineum 
for  the  relief  of  urethral  stricture,  and  that  has  been  described 
under  that  heading  (page  466).  An  incision  having  been  made 
through  the  perineum   and  through  the  urethra  on    to  a  guide 


PROSTATIC  HYPERTROPHY 


569 


placed  in  the  bladder,  the  guide  is  withdrawn,  the  finger  intro- 
duced into  the  wound,  into  the  urethra,  and  as  far  into  the  bladder 
as  possible.     With  the  other  hand  over  the  pubes,  the  surgeon 


Fig.  263. — ^Bryson's  operation  for  relief  of  prostatic  hypertrophy.     The  staff  is  introduced  and 
incision  into  apex  of  prostate  being  made. 


pushes  down  the  bladder  and  the  prostate  so  far  that  they 
can  be  made  to  meet  the  finger  in  the  urethra.  It  will  generally 
be  found,  on  introducing  the  finger  into  the  urethra,  that  quite 


570        DIAGNOSIS    AND   TREATMENT   OF    PROSTATIC    DISEASES 

a  tight  contraction  can  be  felt  just  ahead  of  the  tip  of  the  digit. 
Generally,  in  an  enlarged  prostate,  the  prostatic  urethra  is  nec- 
essarily lengthened  and  contracted  as  a  result  of  the  growth.  In 
this  case  there  may  not  be  room  enough  to  allow  the  finger  to  meet 
the  bladder-wall,  and  the  surgeon  should  cut  down  upon  the  floor 
of  the  urethra,  with  a  small  narrow  bistoury,  as  near  the  anterior 
part  of  the  incision  as  is  required.  If  necessary,  he  may  cut  a 
little  farther  back,  so  as  to  slightly  loosen  the  surrounding  tissue, 
thus  assisting  the  finger  well  up  into  the  prostatic  urethra  ahd 
mouth  of  the  bladder.  Great  care  should  be  taken  during  the 
entire  procedure — and  this  is  most  important — not  to  wound 
the  rectum,  thus  avoiding  the  formation  of  a  recto-urethral  fistula. 
An  assistant  may  introduce  a  finger  into  the  rectum,  or,  while 
this  nick  is  being  made  on  the  floor  of  the  deep  urethra,  the 
surgeon  may  insert  his  finger,  covered  with  a  glove.  Instead  of 
cutting,  a  Kollmann  dilator  may  be  placed  in  the  bladder  and 
the  prostatic  urethra  dilated  to  No.  45.  This  may  be  done  before 
or  after  making  the  perineal  incision.  Any  bands  in  the  prostatic 
urethra  having  now  been  dilated  or  incised  sufficiently  readily 
to  admit  the  forefinger,  a  nick  should  be  made  in  the  wall  of  the 
urethra  on  each  side  from  the  inside.  It  is  important  to  remember 
that  this  slight  cut  is  made  from  inside  the  urethra  out  into  the 
side  lobes  of  the  prostate.  Just  as  a  nasal' surgeon  operating  on 
the  nose  by  means  of  a  probe  breaks  into  the  ethmoid  cells,  a  sur- 
geon operating  on  a  case  of  prostatic  hypertrophy  should  break 
through  the  urethral  wall,  working  from  the  inside  with  his  finger 
into  the  cells  of  the  prostate  lying  on  each  side  of  the  urethra. 
Any  instrument  desired  may  be  used  to  make  the  first  nick,  a 
blunt-pointed  instrument  being  better  than  a  knife  for  this  purpose. 
The  writers  employ  a  periosteal  elevator.  Having  made  the  nick, 
the  surgeon  should  work  his  finger  into  the  opening,  keeping  up  the 
counter-pressure  with  the  other  hand  over  the  bladder,  and,  by 
moving  his  finger  about,  bring  up  whatever  prostatic  mass  he 
may  encounter.  The  ease  with  which  the  mass  or  masses  often 
shell  out  is  astonishing.  They  resemble  small  uterine  fibroids. 
Having  shelled  out  all  the  masses  into  the  prostatic  urethra,  and 
having  freed  them  from  any  attachments,  a  dressing  forceps  should 


PROSTATIC   HYPERTROPHY 


571 


be  introduced  into  the  urethra  from  the  perineal  wound,  and  the 
pieces  removed  through  the  perineal  opening;  the  finger  should 
then  be  inserted  into  the  perineal  opening,  into  the  prostatic  ure- 


Fig.  264.^Bryson"s  operation  for  relief  of  prostatic  hypertrophy,  showing  forefinger  of 
right  hand  enucleating  while  first  and  second  fingers  of  left  hand  are  making  counter-pressure 
from  space  of  Retzius.     Neither  bladder  nor  peritoneum  have  been  opened. 


thra,  and  into  the  opening  in  the  side  of  the  urethra  again,  to  ascer- 
tain if  any  more  masses  exist.  One  side  having  been  cleaned  out, 
a  slit  should  be  made  in  the  other  side  of  the  urethra,  and  any 
growth  remaining  there  removed.  The  masses  may  be  single 
and  the  size  of  a  marble,  or  they  may  be  so  large  and  so  numerous 
as  to  fill  a  coffee-cup,  this  being  dependent  on  the  size  of  the  pros- 


572        DIAGNOSIS   AND   TREATMENT   OF    PROSTATIC    DISEASES 

tate.  It  may  not  be  necessary,  if  the  nicks  are  made  on  each  side 
and  a  third  lobe  enlargement  exists,  to  make  another  opening  at 
the  base  of  the  third  lobe  in  the  floor  of  the  prostatic  urethra  and 
enucleate  this,  for  the  surgeon's  finger  in  one  or  both  of  the  side 
nicks  will  probably  work  its  way  toward  the  front  far  enough  to 
enucleate  the  third  lobe  through  one  of  the  openings  made  in  the 
urethra  from  which  the  side  lobes  were  removed.  If  one  remains 
it  may  be  removed  through  a  slit  at  its  base,  in  the  same  manner 
as  removal  of  the  side  lobe  was  effected.  It  will  be  noticeable 
that,  as  the  enucleation  proceeds  and  the  bunches  are  removed, 
the  prostatic  urethra  will  become  more  and  more  flexible  and  less 
rigid,  and  that  the  hand  on  the  abdomen,  above  the  pubes, 
pushing  the  neck  of  the  bladder  to  meet  the  finger  in  the  ure- 
thra, will  meet  less  and  less  resistance.  This  point  is  important, 
for  if  the  prostatic  urethra  can  be  reached  by  the  surgeon's  finger 
so  that  a  nick  can  be  made  in  the  side  of  it  and  the  enucleation 
proceed,  while  the  hand  above  the  pubes,  the  bladder  being  empty, 
presses  the  prostate  down  from  above,  the  necessit}^  for  making 
any  suprapubic  opening  may  be  avoided.  If  the  prostatic  urethra 
cannot  be  reached, — it  is  generally  only  in  very  fleshy  subjects 
that  this  is  the  case, — a  suprapubic  incision  should  be  made,  just 
as  would  be  done  if  suprapubic  cystotomy  were  to  be  performed, 
except  that  the  bladder  need  not  be  opened.  When  the  bladder 
is  reached,  the  gloved  hand  of  an  assistant  may  be  placed  in  the 
prevesical  space  just  above  that  viscus. 

This  is  quite  roomy,  and  through  it  the  neck  of  the  bladder 
may  be  pushed  down  toward  the  operating  finger. 

Dr.  John  P.  Bryson  was  the  first  operator,  so  far  as  is  known, 
to  discover  this  method  of  utilizing  the  prevesical  space. 

In  some  cases,  particularly  in  the  infirm,  the  very  aged,  or  in 
certain  emergency  operations,  it  may  be  well  to  perform  a  preli- 
minary suprapubic  cystotomy,  and,  at  any  time  within  the 
following  week,  probably  within  the  next  day  or  two,  to 
remove  the  prostate  through  an  incision  in  the  perineum  by  the 
method  just  described.  In  such  cases  an  assistant's  finger  is 
introduced  into  the  bladder,  pressing  the  prostate  down  toward 
the  perineum,  thus  making  it  easier  for  the  operator,  with  his 
finger   in   the   perineal   wound,   to   reach   the   prostatic  urethra. 


PROSTATIC  HYPERTROPHY  573 

Ordinarily,  however,  it  is  not  necessary  either  to  open  the  bladder 
or  to  pass  a  hand  into  the  prevesical  space.  After  the  operation 
an  ordinary  perineal  tube,  of  the  size  of  the  largest  catheter, 
should  be  introduced  into  the  bladder,  the  end  being  allowed 
to  protrude  through  the  perineal  wound.  Strips  of  gauze  should 
be  carefully  packed  all  around,  the  tube  introduced  through 
the  prostatic  urethra  into  the  bladder,  to  lessen  the  danger  of 
secondary  hemorrhage.  Before  introducing  the  tube  the  cavities 
from  which  the  portions  of  the  prostate  have  been  excavated 
should  be  dried  as  carefully  as  possible,  and  the  finger,  well  smeared 
with  ID  per  cent,  iodoform  in  vaselin,  should  be  applied  to  their 
surfaces  in  a  thorough  and  painstaking  manner.  Iodoform,  lo 
per  cent.,  dissolved  in  vaselin  and  melted,  should  also  be  injected 
through  a  glass  syringe  between  the  dressing  on  the  tube  and  the 
urethra.  For  this  suggestion,  which  we  consider  an  excellent 
one,  we  are  indebted  to  our  friend  Dr.  Henry  H.  Morton,  of 
Brooklyn,  the  idea  having  been  conceived  by  his  associate,  Dr. 
H.  E.  Frazer.  The  hemorrhage  at  the  time  of  the  operation  is 
slight  and  easily  controlled  by  douches  of  warm  salt  solution. 
At  the  end  of  six  days  the  perineal  tube  may  be  removed,  the 
wound  allowed  to  granulate  as  after  an  operation  for  stricture 
of  the  urethra,  and  the  patient  permitted  to  get  out  of  bed.  This 
method  of  operating  has  been  criticized  by  some  because  of  the 
danger  of  wounding  the  rectum.  This  accident  is  the  result  of 
either  carelessness  or  ignorance  on  the  part  of  the  operator. 

Among  the  many  advantages  of  this  operation  are  the  follow- 
ing: It  is,  when  properly  conducted,  a  simple  operation;  it  does 
not  remove  or  cut  through  any  more  muscle  or  capsule  than  is 
required;  if  it  does  not  remove  the  whole  prostate,  so  much  the 
better,  so  long  as  it  removes  the  part  that  is  diseased.  The 
various  operations  that  necessitate  going  outside  the  prostate 
through  the  perineum  seem  a  little  more  heroic  than  the  exigen- 
cies of  the  ordinary  case  demand  for  the  relief  of  prostatic  hyper- 
trophy, or  they  remove  more  of  the  prostate  than  is  required. 
The  advantage  that  this  operation  has  over  removal  of  the  pros- 
tate through  a  suprapubic  opening  alone  is  that  it  seems  the  best 
method  for  removing  the  side  lobes  of  the  prostate ;  and  while  these 
lobes  mav  not  be  the  causative  factors  in  certain  forms  of  reten- 


574        DIAGNOSIS   AND    TREATMENT    OF    PROSTATIC    DISEASES 

tion  of  urine,  still  there  is  evidence  to  support  the  view  that  they 
are  responsible  for  the  varicose  condition  of  the  veins  at  the  base 
of  the  bladder,  which  seems  to  aggravate  that  constant  irritation 
almost  always  found  in  cases  of  prostatic  hypertrophy.  Following 
the  operation  a  small  projecting  mass  of  tissue  remains  in  the  floor 
of  the  prostatic  urethra,  and  care  must  be  taken  in  introducing 
the  perineal  tube  and  packing  not  to  bend  it  backward  into  the 
bladder. 

REMOVAL   OF   THE   PROSTATE   THROUGH   A   SUPRAPUBIC 

OPENING 

The  subject  of  suprapubic  cystotomy  has  been  considered  in 

connection  with  bladder  surgerv,  and  it  is  little  more  difficult  to 


Fig.  265.— Fenwick's  operation.    Fin-  Fig.  266.— Fenwick's     operation.     Finger 

ger  entering  prostatic  urethra  (after  Fen-  pushed  sideways  through  wall  of  prostatic  ure- 
wick).  thra  (after  Fenwick). 

remove  a  third  lobe  of  the  prostate  by  means  of  a  suprapubic 
cystotomy  than  it  is  to  perform  the  operation  of  opening  the 
bladder.  The  bladder  having  been  opened  and  the  interior  care- 
fully inspected,  an  incision  may  be  made  over  any  prostatic  growth 
that  may  present  itself,  and  the  mass  be  dug  out  in  much  the 
same  manner  as  in  the  operation  just  described.  This  manner  of 
operating  has  many  advocates,  and  in  properly  selected  cases  it 
may  be  considered  the  operation  of  choice.     After  the  growth  has 


SUPRAPUBIC    REMOVAL    OF    PROSTATE  575 

been  dug  out  by  the  finger  or  pinched  out  by  forceps,  or  teased  out, 


Fig.  267. — Fenwick's  operation.  Finger 
pushing  between  capsule  and  gland  (after  Fen- 
wick). 


Fig.  268. — Fen\vick"s    operation.     Finger 
pushed  still  farther  (after  Fenwick). 


a  little  at  a  time,  the  ordinary  methods  of  checking  hemorrhage 
should  be  employed,  and  a  drainage-tube  inserted  in  the  bladder. 


Fig.  269.— Prostatic  capsule  emptied  of  its  con- 
tents with  torn  ends  of  prostatic  urethra  above  and 
below.  B.  B,  Bladder  base;  u,  urethra;  c,  capsule 
(after  Fenwick). 


Fig.  270. — The  same  healed, 
ends  lining  shrunken  prostatic 
capsule  and  fusing  at  c'  c  (after 
Fenwick). 


If  it  seem  desirable,  an  incision  may  be  made  in  the  perineum  and 
perineal  drainage  established  as  well. 


576        DIAGNOSIS   AND   TREATMENT   OF   PROSTATIC    DISEASES 

E.  Hurry  Fen  wick,  in  a  recent  paper  entitled  "  Vital  Points  in 
the  Technic  of  Suprapubic  Enucleation  of  the  Prostate  for  Benign 


Fig.  271.— Relations  of  the  prostate  and  the  base  of  the  bladder:   P,  Prostate;  B,  bladder; 

R,  rectum. 


Enlargement  of  that  Gland,"  advocates  the  method  of  enucleating 
the  lateral  lobes  of  the  prostate,  which  is  similar  to  the  Bryson 
method  just  detailed,  with  the  exception  that,  as  shown  by  his 
illustrations  (figs.  265  to  270),  he  enucleates  through  the  suprapu- 
bic opening.  He  claims  that,  by  enucleating  these  lobes  through 
breaking  into  the  side  walls  of  the  prostatic  urethra — (i)  there 
is  less  danger'of  injuring  the  vesical  neck ;  (2)  the  wholesale  destruc- 
tion of  the  prostatic  urethra,  with  its  afferent  seminal  ducts,  is 
obviated ;  (3)  the  rough  manipulations  of  the  membranous  urethra 
ordinarily  accompanying  the  usual  enucleation  through  the  supra- 
pubic route  are  rendered  unnecessary.  If  a  third  lobe  is  present, 
it  may  be  removed  separately  through  an  anterior  or  a  posterior 
incision.     He  claims  that  enucleation  of  the  prostate  through  the 


SUPRAPUBIC    REMOVAL   OF   PROSTATE  577 

suprapubic  route  as  ordinarily  carried  out  causes  sterility,  and  is 
likely  to  give  rise  to  the  formation  of  a  dense  mass  of  cicatricial 
tissue  at  the  neck  of  the  bladder.  His  method  is  shown  in  the 
accompanying  illustrations  (Figs.  265  to  270).  Dr.  William  T. 
Belfield,  of  Chicago,  in  1887,  was  the  first  to  report  suprapubic 
operations  on  the  prostate,  followed  by  Mr.  McGill,  of  Leeds, 
England,  in  1888. 

Dr.  Eugene  Fuller,  of  New  York,  was  the  first  to  extensively 
advocate  a  method  for  the  removal  of  the  entire  prostate  supra- 
pubically;  his  method  is  practically  that  adopted  by  Dr.  P.  J. 
Freyer,  about  to  be  described. 

Dr.  P.  J.  Freyer  describes  in  detail  the  manner  in  which  he  oper- 
ates as  follows^ : 

' '  A  catheter  having  been  introduced  into  the  urethra  and 
allowed  to  remain  there,  and  the  prostate  being  pushed  up  by  the 
finger  into  the  rectum,  remove  the  prostate,  scouring  through  the 
mucous  membrane  with  the  finger-nail,  gradually  detaching  it 
by  insinuating  the  finger-tip  in  succession  behind,  outside,  and  in 
front  of  one  lateral  lobe,  this  separating  the  capsule  from  the 
sheath.  The  finger  is  then  swept  in  a  circular  fashion  from  with- 
out inward,  in  front  of  and  to  the  inner  side  of  the  lobe,  detaching 
this  from  the  urethra,  which  is  felt  covering  the  catheter,  and 
pushed  forward  toward  the  symphysis  between  the  lateral  lobes, 
which  will,  as  a  rule,  have  separated  along  their  anterior  com- 
missure in  the  course  of  the  manipulations.  The  other  lobe  is 
attached  and  treated  in  the  same  manner.  The  finger  is  next 
pushed  well  downward  behind  the  prostate,  and  the  inferior  sur- 
face of  the  gland  is  peeled  off  the  triangular  Hgament.  When 
the  prostate  is  felt  free  within  its  sheath  and  separated  from  the 
urethra,  with  the  finger  in  the  urethra,  aided  by  that  in  the  bladder, 
it  is  pushed  into  the  bladder  through  the  opening  in  the  mucous 
membrane  which,  during  the  manipulations,  will  have  become 
considerably  enlarged.  The  prostate,  which  now  lies  free  in  the 
bladder,  is  withdrawn  with  strong  forceps  through  the  suprapubic 
wound." 

He  lays  considerable  stress  on    the  use  of   a  large   drainage- 

1  "  Clinical  Lectures  on  the  Enlargement  of  the  Prostate,"  New  York, 
1906. 

37 


57 8        DIAGNOSIS    AND   TREATMENT  OF    PROSTATIC    DISEASES 

tube  introduced  just  through  suprapubic  wound,  but  not 
allowed  to  strike  the  base  of  the  bladder.  Daily,  through  this 
tube,  the  bladder  is  gently  irrigated.  The  tube  is  a  large  one, 
that  the  urine  and  clots  may  escape  through  it  freely,  and  con- 
sequently there  might  be  no  straining  in  dilating  the  cavity  or 
disturbance  of  the  blood-clot  which  forms  in  the  excavation.     The 


Sheath. 


Triangi 


Fig.  272. — Suprapubic  removal  of  the  prostate  (redrawn  from  P.  J.  Freyer). 

tube  should,  as  a  rule,  be  removed  at  the  end  of  four  days,  and 
the  bladder  irrigated  by  a  nozzle  placed  in  the  suprapubic  opening. 
In  this  operation  the  prostatic  urethra  is  torn  across,  and  some 
portion  removed  without  apparently  increasing  the  mortality. 

It  will  be  noticed  that  care  is  taken  to  avoid  disturbing  the 
blood-clot  which  forms  in  the  excavation  at  the  bottom  of  the 
wound  by  the  use  of  this  large  drainage-tube.  This  really  has 
a  great  deal  to  do  with  the  low  mortality  rate  which  he  reports. 
It  is  our  belief,  in  these  suprapubic  operations  and  the  Bryson 
operatiojQ,  that  it  is  septic  absorption  through  the  wound  in  the 
mucous  membrane  which  is  generally  the  cause  of  death.  That 
is  why  we  are  incHned  to  think  that  the  comparatively  simple 


SUPRAPUBIC   REMOVAL   OF   PROSTATE) 


579 


procedure  of  the  use  of  vaselin  and  iodoform  in  the  Bryson  oper- 
ation, as  mentioned  above,  the  suggustion  of  Dr.  H.  E-  Frazier, 
will  be  found  of  great  benefit. 

European  surgeons  advocate  largely  the  use  of  the  retention 
catheter  for  drainage  purposes  in  these  operations.  The  writers, 
after  considerable  experience  with  the  instrument,  cannot  so  recom- 


Fig.  273. — Suprapubic   prostatectomy,   showing  visual   place   for  incision   in   prostate 
(redrawn  from  Albarran). 


mend  it,  for  in  a  large  number  of  cases  its  use  has  been  followed 
by  inflammation  or  ulceration,  necessitating  its  discontinuance. 

The  after-treatment  of  the  suprapubic  operation  for  the  rehef 
of  an  enlarged  prostate  resembles  that  following  suprapubic  cystot- 
omy for  the  removal  of  a  stone  or  a  tumor.  Albarran  has  modi- 
fied the  suprapubic  operation  for  the  removal  of  the  prostate  in 
the  manner  described  by  Freyer   to  a  slight  extent.     A  sound 


580       DIAGNOSIS   AND   TREATMENT   OF    PROSTATIC    DISEASES 

having  been  introduced  into  the  bladder,  and  the  suprapubic 
opening  having  been  made,  a  circular  incision  with  a  bistoury  is 
made  around  the  neck,  ordinarily  as  shown  in  the  illustration. 
When  at  the  bottom  of  the  neck  the  projections  of  the  median 
lobe  constrains  him  from  making  an  incision,  he  recommends 
raising  it  and  incising  the  mucous  membrane  of  the  bladder  back 
of  the  projecting  part.  When  a  sessile  third  lobe  appears  near 
the  neck  of  the  bladder  he  makes  his  incision  on  the  most  promi- 


Fig.  274. — Vertical  section,  showing  suprapubic  method  of  enucleation  of  the  prostate 
(redrawn  from  Albarran). 


nent  portion  of  it,  always  near  the  orifice  of  the  urethra.  He  lays 
stress  on  making  the  pericervical  incision  of  such  a  depth  that  the 
bistoury  penetrates  into  the  prostatic  tissue.  Ordinarily  the 
incision  is  a  centimeter  in  depth.  His  idea  of  a  somewhat  deep 
incision  is  that  it  makes  it  easier  to  find  the  plane  of  cleavage. 
He  recommends  that  if  the  operator  inserts  his  finger  on  one  side 
and  fails  to  find  the  plane  of  cleavage,  he  try  the  opening  inside 
the  other,  and  eventually  failing  to  find  the  plane,  should  puncture 
the  lateral  lobes  through  the  urethra,  which  is,  according  to  the 


SUPRAPUBIC   REMOVAL   OF    PROSTATE 


581 


method  of  Fenwick,  as  shown   by  the  plates  in   the  preceding 
pages. 

One  other  modification  suggested  by  Albarran  seems  deserving  of 
attention,  and  that  is  his  recommendation  that  the  prostate,  hav- 
ing been  freed  in  all  directions,  should  be  dissected  very  carefully 
from  the  anterior  wall  of  the  urethra  so  as  to  preserve  as  much  of 
the  anterior  wall  of  the  urethra  as  possible,  the  posterior  and 
side  walls  of  the  urethra  in  this  operation  having  been  necessarily 


Fig.  275. — Showing  cavity  left  after  removal  of  prostate  suprapubicaUy  (redrawn  from 

Albarran). 


torn  across  to  a  considerable  extent.  He  recommends  an  incision 
with  the  bistoury  of  that  portion  of  the  anterior  wall  of  the  urethra 
that  remains  adhering  to  the  otherwise  freed  prostate  rather 
than  tearing  it  violently  across.  His  method  is  shown  in  the  illus- 
tration. His  suggestion  as  to  using  as  much  gentleness  as  pos- 
sible in  the  removal  of  the  prostate  instead  of  making  very  violent 
and  brutal  efforts,  seems  worthy  of  special  commendation,  for  the 
more  of  the  membranous  urethra  is  saved  the  less  Hability  of  in- 
continence of  urine  following  the  operation  exists,  and  one  great 


582       DIAGNOSIS   AND    TREATMENT   OF    PROSTATIC    DISEASES 

danger  of  tearing  out  the  prostate  too  violently,  and  especially 
where  it  adheres  to  the  anterior  wall  of  the  urethra,  is  that  of  re- 
moving an  unnecessary  amount  of  the  urethral  wall. 

In  France  it  is  a  popular  custom  to  remove  the  prostate  through 
a  half -moon  incision,  a  speculum  being  used  to  depress  the  floor 


Fig.  276. —  Removal  of  the  prostate  outside  the  capsule  through  straight  perineal  incision. 
The  membranous  urethra  is  opened  on  a  grooved  staff;  the  rectal  tissues  are  pulled  down- 
ward (after  Deaver). 

of  the  rectovesical  space.  The  prostate  being  reached,  the  capsule 
is  opened  and  turned  back  to  each  side  like  a  cuff,  the  membranous 
urethra  incised,  then,  with  or  without  the  use  of  a  depressor,  the 
side  lobes  removed,  and  the  third  lobe,  if  present,  is  removed  by  in- 
troducing a  finger  through  the  incision  into  the  bladder,  inverting 
the  third  lobe  through  the  wound  in  the  prostatic  urethra  and  thus 
removing  it.  A  retention  catheter  into  bladder  emerging  through 
meatus;  another  drainage-tube  into  rectovesical  space.  This  is 
practically  the  operation  of  Proust  and  Albarran. 


SUPRAPUBIC   REMOVAL   OF    PROSTATE  583 

In  the  operation  of  Hugh  Young,  of  which  a  detailed  description 
should  be  carefully  studied/  a  particular  effort  is  made  to  save  the 
integrity  of  the  ejaculatory  ducts.  It  is  of  the  general  character 
of  the  operations  just  described,  an  ingeniously  devised  prostatic 
tractor  and  several  retractors  lending  aid  to  the  ease  of  its  per- 
formance, which  can  be  accomplished  very  rapidly  by  one 
familiar  with   its   technique.     In  order  to  get  the  patient  into 


Fig.  277. — P.emoval  of  the  prostate  outside  the  capsule  through  straight  perineal  incision. 
By  means  of  Fergusson's  depressor  the  prostate  is  pulled  well  down  into  the  perineum. 
The  sheath  of  the  prostate  has  been  incised  over  each  lateral  lobe  (after  Deaver). 

the  proper  position,  so  that  room  may  be  afforded  for  the  use 
of  the  speculum  to  open  up  the  rectovesical  space,  it  is  neces. 
sary  to  use  an  Albarran  speculum  or  to  place  the  patient  on  a 
box  of  certain  shape,  supporters  for  the  legs  of  a  certain  form 
should  also  be  used.  These  are  illustrated  in  the  following  plates, 
and  can  be  obtained  through  Tiemann  &  Co.,  New  York.  A 
^  "Keen's  Surgery,"  Vol.  IV.,  W.  B.  Saunders  Company. 


584       PROGNOSIS    AND   TREATMENT    OI^    PROSTATIC    DISEASES 

very  popular  operation,  when  it  is  desired  to  remove  a  prostate 
from  outside  the  capsule  and  by  the  perineal  route,  is  to  make  a 
long,  straight,  perineal  incision;  also  incise  the  membranous  ure- 
thra, and  with  a  Fergusson  depressor  pull  the  prostate  down  into 
the  perineal  wound  and  then  enucleate  it,  as  shown  in  the  illustra- 
tions (figs.  266  to  268).  Speaking  from  a  strictly  surgical  point  of 
view,  the  operation,  as  performed  in  France,  whereby  the  prostate 


Fig.  278. — Removal  of  prostate  outside  the  capsule  through  straight  perineal  incision.  By 
blunt  dissection  and  with  the  aid  of  Murphy's  hooks  as  tractors  each  lateral  lobe  is  removed 
in  turn.  Drain  with  tube  in  bladder  or  through  the  perineal  wound,  the  tube  being  well 
packed  (after  Deaver). 

is  exposed  through  a  semilunar  incision  through  the  perineum, 
and  well  brought  into  view  through  a  proper-shaped  speculum, 
by  which  the  space  is  opened,  is  a  useful  one,  from  the  fact  that 
no  excavation  in  the  mucous  membrane  is  left  behind  through 
which  septic  absorption  can  take  place,  as  is  the  case  when  the 
suprapubic  method  is  followed  or  the  Bryson  operation  performed. 


SUPRAPUBIC   REMOVAL   OF    PROSTATE 


585 


The  operation  just  mentioned,  however,  unless  the  surgeon  is 
famihar  with  the  rectovesical  space,  is  attended  with  danger  of 
wounding  the  rectum,  and  for  the  inexpert  takes  longer  than 
either  the  Bryson  or  the  suprapubic  operation  to  perform. 


Fig.  279.— Illustrating  leg  supporters  and  position  of  patient  for  removal  of  prostate  in 
Albarran  and  Proust's  operation  (redrawn  from  Pierre  Duval). 

The  simple  procedure  mentioned  before,  of  applying  iodoform 
and  vaselin  after  the  Bryson  operation,  or  the  use  of  the  large 
drainage-tube  of  Freyer,  after  the  suprapubic,  tends  to  obviate 
the  danger  of  sepsis  to  a  very  marked  degree. 

From  personal  and  contributed  experience  the  writers  are  in- 
clined to  recommend  the  perineal  route,  performed  in  the  man- 


586        DIAGNOSIS   AND   TREATMENT   OF    PROSTATIC    DISEASES 

ner  described  under  the  name  of  the  Bryson  operation.  Where, 
however,  the  enlargement  is  almost  entirely  of  the  third  lobe;  where 
there  is  but  slight  congestion  due  to  varicose  veins  at  the  base  of  the 
bladder,  and  where  the  proper  after-treatment  of  the  suprapubic 
wound  can  be  secured,  the  removal  of  this  third  lobe  of  the  pros- 
tate by  the  suprapubic  route  may  at  times  be  advisable. 


Fig.  280. — Illustrating  the  removal  of  prostate;  incision  through  prostatic  urethra. 
Speculum  in  position  at  base  of  figure.  Method  of  Albarran  and  Proust  (redrawn  from 
Pierre  Duval). 

Partial  Prostatectomy. — Criticism  of  the  Bryson  operation 
has  been  made  that  it  does  not  remove  the  entire  prostate.  Judg- 
ing from  our  experience  up  to  the  present  time  it  is  doubtful 
whether  such  criticism  is  founded  on  the  proper  understanding 
of  the  underlying  conditions.  While  from  a  mechanical  and 
purely  surgical  standpoint  the  total  removal  of  the  prostate 
may  ordinarily  be  the  object  desired,  from  the  standpoint  of  the 
patient   and   possibly    from    the   physiologic   standpoint   an    in- 


TUMORS  OF  THE   PROSTATE  587 

complete  removal  may  not  infrequently  furnish  all  the  relief 
desired  either  through  the  removal  of  the  lateral  lobes  through 
the  Bryson  operation,  or  suprapubically  when  a  median  lobe  alone 
presents  itself.  It  is  interesting  to  note  that  to  the  best  of  our 
knowledge  the  fathers  of  suprapubic  removal  of  the  prostate, 
Dr.  Wmiam  T.  Belfield,  of  Chicago,  and,  Mr.  McGill,  of  Leeds, 
England,  had  this  in  mind  in  their  first  operations.  This  may 
again  come  into  vogue,  just  as  at  the  present  time  conservative 
operations  on  the  ovaries  are  much  more  popular  than  was  their 
complete  removal  a  few  years  ago.  As  far  as  our  personal  ob- 
servation is  concerned  a  complete  total  enucleation  of  the  prostate 
seems  to  have  a  more  depressing  effect  on  the  nervous  system 
of  the  individual  following  the  operation  than  happens  when  some 
little  prostatic  tissue  is  left  behind.  In  addition,  the  saving  of  as 
much  as  possible  of  the  urethra  renders  the  incontinence  of  urine 
less  liable  to  occur.  Whether  or  not  any  internal  secretion  of 
the  prostate  may  play  a  part  in  conserving  the  general  nerve 
tone  of  the  individual  is  not  a  proper  subject  for  discussion  here, 
but  the  personal  observation  of  the  writers  is  as  stated  above. 

TUMORS  OF  THE  PROSTATE 
Excluding  prostatic  hypertrophy,  which  the  writers  consider 
non-neoplastic  and  inflammatory  in  nature,  tumors  of  the  pros- 
tate gland  occur  less  frequently  than  is  generally  believed.  Fibro- 
mata of  the  prostate,  which  are  commonly  reported,  usually  occur 
as  a  result  of  inflammation  and  are  but  rarely  true  idiopathic 
neoplasms.  Myomata,  invariably  of  the  smooth  muscle  type,  are 
occasionahy  seen,  but  seldom  grow  to  large  size  or  have  any  cHnical 
significance.  Sarcoma  of  the  prostate  is  rare,  except  when  it 
occurs  in  the  course  of  a  general  sarcomatosis.  Hypernephroma 
of  the  prostate  occurs  as  a  somewhat  rare  metastatic  growth,  the 
writers  having  seen  but  two  cases.  Its  recognition  clinically  is  of 
but  slight  importance,  however,  since  it  appears  only  in  hopeless 
conditions  in  which  metastasis  is  general  and  beyond  surgical 
relief.  Carcinoma  of  the  prostate  gland  is  unquestionably  the 
most  frequent  form  of  tumor,  although  prostatic  cancer  was  for- 
merly considered  a  very  rare  condition ;  Alberran  and  Halle  were 
the  first  to  recognize  and  report  its  frequency  of  occurrence.     The 


588        DIAGNOSIS    AND   TREATMENT   OF    PROSTATIC    DISEASES 

writers  have  found  it  most  often  in  hypertrophied  prostates,  in 
which  the  interstitial  hyperplasia  and  inflammatory  exudate,  with 
the  resulting  epithelial  proliferation,  frequently  give  rise  to  the 
development  of  cancerous  growths  in  the  enlarged  gland,  just  as 
similar  conditions  also  induce  malignant  disease  in  the  mammary 
gland.  Young,  in  a  recent  publication,  finds  cancerous  altera- 
tions present  in  about  7  per  cent,  of  his  cases  of  prostatic  hyper- 
trophy, fully  corroborating  the  statement  previously  made  regard- 
ing its  frequency.  On  account  of  the  great  clinical  importance  of 
prostatic  cancer  it  has  seemed  best  to  discuss  it  fully  under  a 
separate  heading. 

Carcinoma  of  the  Prostate. — In  few,  if  any,  of  the  organs  of  the 
body  are  the  changes  that  transform  a  simple  inflammatory  process 
to  a  cancer  more  easily  demonstrated  than  in  the  prostate.  First, 
the  simple  inflammator}^  process  obliterates  the  mouth  of  one  of 
the  acini  of  the  prostate ;  epithelial  cells  are  thrown  off  inside  the 
acini  and  are  unable  to  escape;  the  distention  of  the  acini,  as 
mentioned  in  connection  with  the  pathology  of  prostatic  hyper- 
trophy, goes  to  make  up,  to  a  great  extent,  the  various  enlargements 
of  the  organ.  Just  so  long  as  these  cells  remain  inside  the  acini 
a  simple  inflammatory  process  is  present;  as  soon  as  these  cells 
break  through  the  acini  and  invade  the  surrounding  tissues  cancer 
occurs.  If  one  could  tell  what  process  causes  these  cells,  at  one 
time  benign,  to  remain  within  the  walls  of  the  acini,  and  later  on 
to  wander  under  malignant  impulses  through  the  surrounding 
tissues,  the  problem  as  to  the  nature  of  cancer  occurring  in  any 
portion  of  the  body  would  be  solved. 

Cancer  of  the  prostate  was  first  recognized  in  181 7.  At  that 
time  this  growth,  together  with  sarcoma  and  the  ordinary  so-called 
hypertrophy  of  the  prostate,  was  considered  under  the  head  of 
cirrhus  tumor ;  it  is  only  during  the  past  few  years  that  a  differen- 
tiation has  been  made  between  cancer  and  sarcoma  of  the  prostate. 
Still  more  recently,  as  the  result  of  the  large  number  of  sections 
made  through  prostates,  cancer  of  small  size  has  been  found  to 
occur — so  small  as  occasionally  to  be  confined  to  one  lobe  of  the 
organ. 

It  is  not  easy,  from  statistics  at  present  obtainable,  to  draw 
positive  conclusions  as  to  the  frequency  with  which  primary  can- 


TUMORS  OF  THE   PROSTATE 


589 


cer  of  the  prostate  really  appears;  but,  since  the  so-called  hyper- 
trophied  prostate  in  the  aged  is  a  chronic  inflammatory  process, 
cancer  may  be  expected  to  follow  in  a  large  proportion  of  such 
cases,  just  as  it  follows  chronic  inflammation  attacking  other 
glands  of  the  body.    Cancer  of  the  prostate  is  being  reported  with 


Fig.  281. — Microphotograph  of  cancer  of  the  prostate. 

increased  frequency,  and  when  it  is  remembered  that  a  cancer 
may  be  so  small  as  to  be  situated  entirely  within  one  lobe  of  the 
prostate,  it  may  be  seen  how  easily  such  growths  may  escape 
recognition.  A  case  of  very  small  cancer  of  the  prostate  was 
operated  upon  by  one  of  the  writers.  Being  confined  to  one  lobe, 
it  w^as  discovered  only  after  the  prostate  had  been  removed  and 
sections  made  through  it.  It  had  been,  nevertheless,  the  cause 
of  much  suffering,  giving  intense  perineal  pain.  The  prostate 
was  otherwise  comparatively  healthy.  Three  years  after  the 
operation  there  was  no  indication  of  recurrence. 

In  a  paper  published  by  the  writers,^  the  findings  of  a  careful 
examination  of   fifty-eight  enlarged  prostates  are  set  forth:    in 
three  of  these  cancer  was  present.    The  writers  are  convinced  that 
1  Greene  and  Brooks:  "  Hypertrophy  of  the  Prostate,"  1903. 


590       DIAGNOSIS   AND   TREATMENT   OF   PROSTATIC    DISEASES 

cancer  of  the  prostate  occurs  in  from  5  to  10  per  cent,  of  old  men 
suffering  from  prostatic  hypertrophy,  and,  further,  that  occa- 
sionally cancers  that  are  believed  to  occur  primarily  in  other  por- 
tions of  the  body,  are  really  secondary  to  unrecognized  prostatic 
carcinomata. 

Glandular  metastasis  occurs  in  about  nine-tenths  of  those  cases 
of  cancer  of  the  prostate  so  far  advanced  as  to  be  easily  recog- 
nizable. About  30  per  cent,  exhibit  inguinal  gland  enlargement, 
the  axillary  and  subclavicular  glands  being  those  next  most  com- 
monly affected. 


Fig.  282. — Microphotograph  showing  development  of  cancer  in  a  sclerotic  hypertrophied 

prostate. 

Age. — It  is  difficult,  from  the  literature  on  the  subject,  to  state 
definitely  the  earliest  age  at  which  cancer  of  the  prostate  may 
occur.  One  case  is  recorded  occurring  in  a  man  of  thirty-eight; 
the  average  age,  however,  seems  to  be  over  fifty,  and  in  one  series 
of  nineteen  cases  it  was  sixty-eight.  In  a  large  majority  of  the 
cases  recorded  a  history  of  symptoms  pointing  toward  prostatic 
disorders,  of  several  years'  standing,  is  generally  given. 

Cachexia. — This  S5miptom  has  been  strongly  dwelt  upon  by  most 
writers  on  the  subject.     It  may  be  of  diagnostic  value  in  so  far  as 


TUMORS    OF   THE    PROSTATE 


591 


its  comparatively  sudden  appearance  in  old  prostatics,  without 
other  accountable  reason,  would  naturally  indicate  that  a  malig- 
nant disease  might  be  developing;  or  it  might  tend  to  increase 
the  value  of  any  other  evidence  pointing  in  that  direction. 


Fig.  283— Total  removal  of  prostate.     Membranous  urethra  is  incised  (redrawn  frore 

Pierre  Duval). 

Pain. — Pain  almost  invariably  accompanies  cancer  of  the  pros- 
tate, and  may  be  the  first  symptom  to  awaken  the  suspicion  of 
the  existence  of  maUgnant  disease.  The  pain  may  be  referred  to 
the  prostate, — that  is,  to  the  perineal  region, — to  the  rectum,  to 
the  back  over  the  region  of  the  kidney,  to  various  portions  trav- 
ersed by  branches  of  the  sciatic  nerve,  to  the  region  of  the  bladder, 
or  to  the  glans  penis.  It  may  apparently  arise  directly  from  the 
prostate,  or  indirectly  from  the  pressure  of  glands  that  may  have 
become  infected.  As  has  been  said,  it  may  be  the  first  S3anptom 
to  give  rise,  in  the  mind  of  the  observer,  to  the  suspicion  of  malig- 


592         DIAGNOSIS   AND   TREATMENT   OF   PROSTATIC    DISEASES 

nant  disease,  and  as  it  may  occur  before  metastasis  into  the  neigh- 
boring lymphatics  has  taken  place.  Persistent  pain  occurring  in 
an  old  prostatic,  without  other  explanation  to  account  for  it, 
should  ordinarily  lead  to  early  surgical  intervention. 


Fig.  284. — Total  removal  of  prostate.     Prostate  being  removed  (redrawn  from  Pierre 

Duval). 


Hematuria. — Next  to  pain,  bloody  urine,  occurring  perhaps  in 
50  per  cent,  of  cases,  is  the  most  common  symptom  in  cancer  of 
the  prostate.  Careful  use  of  the  cystoscope  will  determine  in 
any  given  case  the  cause  of  the  bloody  urine. 

Physical  Examination. — The  amount  of  residual  urine  is  of  no 
particular  diagnostic  value.  Cases  of  cancer  of  the  prostate  have 
been  reported  in  which  hardly  any  residual  urine  was  present — in 
one  case  only  a  tablespoonful.  This  is  not  remarkable  in  view 
of  the  fact  that  cancer  may  occur  without  sufficiently  increasing. 


TUMORS    OF    THE    PROSTATE 


593 


the  size  of  the  prostate  to  cause  marked  obstruction  to  the  urinary 
outflow.  It  must  also  be  remarked  that  almost  all  these  cases 
give  a  history  of  previous  gonorrhea  or  injury. 

The  size  and  feel  of  the  prostate,  as  ascertained  by  rectal  touch 
or  by  urethral  examination,  are  probably  not  in  themselves  of 
any  great  diagnostic  value,  except  as  a  means  of  comparison. 


Fig.  285. — Total  removal  of  prostate.    Neck  of  bladder  stitched  to  membranous  urethra, 
prostate  having  been  removed  (redrawn  from  Pierre  Duval). 


These  prostates  may  feel  hard,  nodular,  or  even  soft.  A  sensa- 
tion conveyed  to  the  rectal  touch  as  of  a  bunch  in  the  prostate, 
or  the  feel  of  a  cyst,  the  contents  of  which  cannot  be  removed  by 
massage  of  the  gland,  is  considered  by  some  as  diagnostic  of  can- 
cer. Examinations  made  to  compare  the  size  and  consistency  at 
different  times  may  thus  be  of  value.  In  an  old  prostatic  whose 
gland  has  remained  of  about  the  same  proportion  for  a  long  time, 
as  determined  by  rectal  or  urethral  examination,  a  sudden  increase 
38 


594        DIAGNOSIS   AND   TREATMENT  OF    PROSTATIC    DISEASES 

in  size  is  indicative  of  malignant  disease  or  inflammatory  exacer- 
bation. Cancer  of  the  prostate  is  more  likely  to  arise  in  the  lateral 
lobes  or  in  one  of  them  rather  than  in  the  so-called  third  lobe. 

Prognosis. — In  these  cases  the  prognosis  is,  of  course,  grave,  and 
where  metastasis  has  begun,  almost  invariably  fatal.  The  writers 
believe  that  if  the  diagnosis  is  made  early  enough,  the  cancer  may 
be  eradicated  by  surgical  interference.  Almost  all  the  cases  re- 
ported as  having  been  operated  upon  have  done  badly  so  far  as 
cure  is  concerned.  In  the  writers'  case,  previously  referred  to,  the 
recovery  which  took  place  after  the  operation  was  in  all  probability 
due  to  the  fact  that  the  prostate  was  removed  before  the  cancer 
had  time  to  cause  glandular  metastasis. 

Treatment. — The  treatment  may  be  considered  under  three 
heads — preventive,  palliative,  and  curative. 

Preventive. — The  ultimate  analysis  of  the  question  of  preventive 
treatment  seems  to  lead  to  the  conclusion  that  if  gonorrhea  or 
any  urethral  inflammatory  process  could  be  prevented  in  the 
first  place,  cancer  of  the  prostate  would  become  much  less  fre- 
quent, for  it  is  now  well  established  that  chronic  posterior  ure- 
thritis is  a  very  frequent  complication  of  acute  urethritis.  More 
and  more  evidence  is  being  brought  out  to  demonstrate  that  chronic 
posterior  urethritis  and  chronic  prostatitis  go  hand  in  hand ;  that 
the  latter  plays  a  causative  role  in  the  formation  of  the  so-called 
prostatic  hypertrophy,  and  that  this  in  turn,  reasoning  from 
analogy,  plays  a  part  in  the  formation  of  cancer.  It  would  seem 
also  that  more  prolonged  and  careful  treatment  of  chronic  pos- 
terior urethritis  and  prostatitis  would  tend  to  prevent  the  so-called 
hypertrophy  and,  secondarily  thereto,  the  cancer. 

Palliative. — From  the  literature  on  the  subject  it  will  be  seen 
that  in  most  recorded  cases  of  cancer  of  the  prostate  the  diagnosis 
has  been  made  only  after  metastasis  had  taken  place  and  general 
systemic  infection  occurred.  Consequently  the  operations  at- 
tempted in  the  hope  of  effecting  a  cure  have  proved  failures.  Some- 
thing may  be  said,  however,  in  favor  of  operations  performed  for 
the  purpose  of  prolonging  life,  or,  more  particularly  in  the  later 
stages  of  the  disease,  for  the  relief  of  symptoms,  especially  pain. 
From  the  writers'  experience  with  palliative  operations  in  tuber- 
culosis  and   cancer  occurring  in   other  portions   of   the   genito- 


TUMORS   OF  THE   PROSTATE  595 

urinary  tract,  they  conclude  that  such  operations  are  justifiable  in 
prostatic  carcinoma,  but  they  believe  that  they  should  not  be 
attempted  if  they  are  likely  to  make  the  progress  of  the  disease 
more  distressing  to  the  patient. 

Curative. — So  far,  the  only  curative  procedure  known  consists 
in  removing  the  cancerous  prostate  before  metastasis  has  taken 
place.  Now  that  this  condition  is  receiving  more  attention,  it  is 
to  be  hoped  that  an  earlier  recognition  will  result  in  the  recovery 
of  a  larger  number  of  patients. 

In  certain  forms  of  cancer  of  the  prostate  total  extirpation  of 
the  prostate,  with  amputation  of  the  prostatic  urethra,  as  illus- 
trated in  the  method  of  Proust  (figs.  283,  284,  and  285),  may 
be  found  necessary. 


CHAPTER  XXVIII 
THE  TESTICLE  AND  EPIDIDYMIS 

ANATOMY 

The  testicle  is  a  compound  tubular  gland  of  complicated  struc- 
ture. It  produces  a  secretion,  the  spermatozoa,  which  form  the 
essential  of  the  seminal  discharge. 

The  testicle  is  invested  by  a  reflection  of  the  peritoneum.  This 
gives  it  its  outer  or  serofibrous  coat,  which  is  not  applied  close  to 
the  surface  of  the  organ,  but  is  derived  as  it  passes  from  the  abdom- 
inal cavity  into  the  scrotum;  this  is  known  as  the  tunica  vagi- 
nalis. 

The  gland  is  inclosed  and  limited  by  a  strong,  thick  cap- 
sule called  the  tunica  albuginea.  This  is  a  dense,  unyield- 
ing membrane  of  white  color;  it  is  composed  of  compact  bundles 
of  white  fibrous  tissue  that  interlace  in  various  directions.  Its 
inner  layer  is  richly  supplied  with  blood-vessels  and  is  sometimes 
called  the  tunica  vasculosa. 

In  the  interior,  fibers  from  the  tunica  albuginea  are  prolonged 
from  the  posterior  border  for  a  short  distance,  into  the  gland,  so 
as  to  form  the  complete  vertical  septum  called  the  corpus  high- 
morianum,  or  the  mediastinum  testis.  This  septum  contains  the 
larger  blood-vessels  of  the  gland. 

From  the  front  and  sides  of  the  mediastinum  are  given  off  nu- 
merous slender  fibrous  cords  and  imperfect  connective-tissue  septa 
that  radiate  from  the  mediastinum  toward  the  opposite  wall  of 
the  albuginea,  with  which  the  ends  of  the  septa  blend.  In  this 
manner  the  gland  is  divided  off  into  from  loo  to  200  more  or  less 
imperfect  lobes.  The  septa,  although  made  up  of  connective 
tissue,  also  contain  a  few  smooth  muscle-fibers  and  transmit 
branches  of  the  mediastinal  arteries  to  all  parts  of  the  gland  struc- 
ture. They  also  inclose  certain  large  connective-tissue  cells,  the 
cytoplasm  of  which  is  rich  in  metaplasm. 

596 


PLATE  XVIII 


.      .  ^        lobiilis  of      titiiiat 
"hisims   J/^"'i""j'   "iiwuinea  spermatic  cord  \ 


head  of  Zlr-'^T' 

appendix  oj 
epididymis 

nil  dial  surface 


nifiior  border 

spcniiulic  cord '- 


lateral  siirjai 


infciior  c 


a 


I  J\lunica  vaginalis 
communis 


tunica  vaginalis  propria 
superior  ligament  of  cpidid\mis 

sinus  of  epididymis 

posterior  border  of  testis 
inferior  ligament  of  epidid)  mi 

tail  of  epididymi. 


ica  vaginalis  communis  I 

Iliad  of  epididymis 
appendix  of  testis 
appendix  of  epididymis 


hileral  siirj'aec 
of  testis 


anterior  border 
of  testis 


a,  The  testis  and  epididymis  with  their  investing  membranes  seen  from 
in  front,  b,  seen  from  the  lateral  surface;  c,  the  testis,  epididymis,  and  the 
proximal  portion  of  the  vas  deferens.  The  tunica  albuginea  has  been  com- 
pletely removed  from  the  epididymis  and  partly  from  the  testis ;  the  tubuH 
contorti  of  the  lowest  lobule  of  the  testis  have  been  isolated  (Sobotta  and 
McMurrich). 


ANATOMY  597 

The  glandular  or  secreting  portion  of  the  testis  is  inclosed  and 
supported  by  this  connective-tissue  framework  just  described, 
made  up  of  the  tunica  albuginea,  the  mediastinum,  and  the  septa. 
The  glandular  portion  consists  of  the  seminiferous  tubules  and  of 
their  excretory^  ducts.  Each  compartment  or  lobe  contains  two, 
three,  or  more  tubules,  all  of  which  extend  out  from  the  medias- 
tinum in  a  comparatively  straight  course,  but  become  greatly 
convoluted  and  entwined  about  one  another  as  they  extend  toward 
the  peripher>%  The  length  of  the  individual  tubule  varies  some- 
what when  straightened  out — some  of  them  are  found  to  be  as 
much  as  twenty  inches  long. 

The  seminiferous  tubules  may  be  divided  into  three  portions — 
the  convoluted  tubules,  the  loops  of  which  make  up  the  bulk  of  the 
lobe;  the  straight  tubules,  which  are  the  terminations  of  the  con- 
voluted tubules  and  are  found  at  the  apex  of  the  lobule ;  and  the 
tubules  into  which  the  straight  tubes  empty,  and  which  are  seen 
in  the  mediastinum ;  these  make  up  the  rete  testis. 

The  seminiferous  tubules  are  lined  throughout  with  epithelium, 
which  varies  in  different  portions  of  the  tubule  and  presents,  in 
parts,  a  compUcated  arrangement.  In  all  portions  the  epithe- 
lium is  laid  down  on  a  basement  membrane  composed  of  several 
layers  of  flattened  endothelioid  connective-tissue  cells;  outside 
this  cellular  layer  a  fibrillar  membrane  is  found. 

The  active  secretory  function  of  the  tubule  takes  place  in  the 
convoluted  portions,  and  it  is  here  that  we  find  the  epithelium 
taking  on  its  most  complicated  arrangement  and  form. 

In  the  convoluted  tubules  three  varieties  of  epithehal  cells  are 
found:  first,  the  cells  arranged  on  the  basement  membrane, 
named  the  spermatogonia;  next,  a  layer  of  cells,  often  two  or  three 
deep,  called  the  spermatocytes,  and,  finally,  the  innermost  of  all, 
the  spermatids. 

The  spermatogonia  are  of  two  varieties :  first,  and  most  numer- 
ous, the  irregular  polygonal  or  oval  cells  whose  nuclei  are  rich  in 
chromatin ;  between  these,  at  irregular  inter^^als,  are  seen  certain 
tall,  thin  cells  that  project  upward  nearly  into  the  lumen  of  the 
tubule,  and  are  called  the  columns  of  Sertoli  or  the  susten- 
tacular  cells.  These  take  no  active  part  in  the  formation  of  the 
spermatozoa,   but   only   support   the   polygonal   cells   so   closely 


598  THE    TESTICLE    AND   EPIDIDYMIS 

crowded  around  them,  from  which  the  spermatozoa  develop. 
This  development  takes  place  from  the  rapid  division  of  the  poly- 
gonal cells,  after  an  interval  of  rest,  these  primary  spermatocytes, 
grouped  about  the  columns  of  Sertoli  divide  again,  so  that,  finally, 
each  primary  spermatocyte  is  doubled;  next  each  spermatocyte 
divides  into  two  spermatids,  each  of  which  incloses  a  centrosome 
and  is  very  rich  in  chromatin  derived  from  the  original  nucleus. 
Cytoplasm  is  somewhat  scant}'  in  the  spermatids. 

From  the  spermatids  are  developed  the  spermatozoa,  but  the 
manner  in  which  this  development  takes  place  is  still  an  undecided 
question.  At  any  rate,  the  chromatin  of  the  spermatids  cleaves, 
and  from  the  resulting  stages  the  spermatozoa  are  formed  from  the 
chromatin.  Some  believe  that  the  entire  spermatozoon  is  derived 
from  the  chromatin,  whereas  others  hold  that  only  the  head  and 
body  are  so  formed,  the  tail  being  derived  from  the  cytoplasm. 

Spermatogenesis  does  not  take  place  in  every  part  of  the  testicle 
at  the  same  time.  Some  tubules  are  in  a  quiescent  or  resting 
stage,  while  others  carry  on  the  secretory  function;  then  the  active 
cells  pass  to  a  resting  stage,  and  the  recuperated  ones  take  up 
the  active  function. 

The  straight  tubules  are  much  smaller  than  the  convoluted 
tubules,  and  are  lined  by  a  single  layer  of  low  columnar  or  cuboid 
cells. 

In  the  rete  testis  the  tubules,  now  excretory  ducts,  vary  much 
in  size  and  shape — from  narrow  clefts  and  channels  to  large  open 
tubules;  they  are  lined  by  a  single  layer  of  flattened  epithelial 
plates. 

The  tubules  of  the  rete  testis  coalesce  to  form  about  ten  or 
twelve  tubules  called  the  vasa  efferentia,  which  emerge  from  the 
limitations  of  the  testis  and  are  thrown  into  numerous  folds,  mak- 
ing up  the  globus  major  or  the  head  of  the  epididymis.  The  tubes 
are  lined  by  a  simple  or  stratified  columnar  epithelium  which  is 
covered  with  long  cilia  which,  in  the  fresh  condition,  wave  away 
from  the  testis.  This  epithelium  is  arranged  on  a  thick,  fibrous 
wall  in  which  are  included  some  smooth  muscle-fibers. 

The  body  and  tail  of  the  epididymis  are  made  up  of  the  convolu- 
tions of  the  tubules,  which  in  turn  are  a  continuation  of  those 
which  make  up  the  globus  major;    and  this  is  continued  as  the 


PATHOLOGY   OF    DISEASES    OF    THE    TESTICLE  599 

Spermatic  duct  or  the  vas  deferens,  which  is  a  tubule  about  20  inches 
in  length,  extending  from  the  epididymis  to  the  root  of  the  penis. 
The  walls  of  the  vas  deferens  are  made  up,  first,  of  an  internal 
coat  of  ciliated  epithelium  laid  down  on 'a  somewhat  thick  base- 
ment membrane,  beneath  which  is  a  quite  thin  layer  of  areolar 
connective  tissue,  followed  by  an  inner  circular  and  an  outer 
longitudinal  coat  of  smooth  muscle. 

The  vas  deferens  passes  through  the  prostate  gland  to  the  neck 
of  the  bladder,  where  it  presents  on  each  side  an  ampulla  or  dila- 
tation that  empties  through  the  ejaculatory  duct  into  the  urethra. 

Blood  and  Nerve  Supply. — The  testicles  and  epididymis  are  nour- 
ished by  the  spermatic  arteries,  which  arise  directly  from  the  aorta. 
The  veins  of  both  testicle  and  epididymis  unite  as  they  ascend 
along  the  cord,  about  which  an  intimate  venous  anastomosis, 
known  as  the  pampiniform  plexus,  is  formed.  The  nerves  are 
derived  from  the  sympathetic  system  and  the  spermatic  plexus 
is  connected  with  the  renal  and  aortic  plexuses. 

The  lymphatics  follow  the  general  course  of  the  blood-vessels 
and  drain  into  the  lumbar  lymph-nodes. 

THE  PATHOLOGY  OF  DISEASES  OF  THE  TESTICLE 
Defects. — Complete  absence  of  the  testicles  is  occasionally  met  as  a 
congenital  defect,  being  usually  associated  also  with  absence 
of  the  epididymis,  vas,  and  seminal  vesicles.  The  absence  of  a 
single  testicle,  the  result  of  some  defect  of  development,  is  rela- 
tively a  common  occurrence,  but  is  usually  due  to  some  disease 
of  the  nutrient  arteries  in  the  early  stages  of  development;  such 
being  the  case,  it  is  not  uncommonly  seen  when  both  vas  and 
epididymis  of  the  same  side  are  present. 

Cases  of  supernumerary  testicle  are  occasionally  reported,  but  a 
microscopic  examination  demonstrates  that  in  most  cases  the  sup- 
ernumerary bodies  are  not  true  testicles.  Such  conditions  ordi- 
narily give  rise  to  no  symptoms.  The  differential  diagnosis  must 
generally  be  made  from  hydrocele  and  hernia. 

Micro-orchia  or  hypoplasia  of  one  or  both  testicles  is  a  rela- 
tively frequent  condition.  As  a  rule,  it  is  associated  with  other 
defects  of  development,  although  it  is  occasionally  seen  in  other- 
wise normal  persons.     As  a  rule,  when  both  organs  are  involved, 


600  THE    TESTICLE    AND   EPIDIDYMIS 

the  bod}'  shows  lack  of  sexual  development,  the  general  type  of 
an  asexual  individual  pertaining.  In  nearly  all  instances  the 
organs  represent  delayed  development,  and  are  found  in  a  stage 
representing  early  formation.  Spermatogenesis  does  not  take 
place,  and,  in  so  far  as  its  influence  on  the  body  as  a  whole  is 
concerned,  the  testicle  may  be  considered  as  practically  absent. 

Monorckidism  or  ayptorchidism  is  the  condition  in  which  one 
or  both  organs  are  retained  in  the  abdominal  cavity,  in  the  exter- 
nal or  internal  ring,  or  in  the  inguinal  canal,  and  fail  to  pass  into 
the  scrotum.  The  condition  depends  upon  prenatal  disease,  such 
as  abnormal  closure  of,  or  a  small  inguinal  canal,  a  short  guber- 
naculum,  or  adhesions  to  the  abdominal  or  pelvic  viscera.  Under 
such  conditions  the  organs  are  not  infrequently  more  or  less  hypo- 
plastic, although  in  many  cases  of  double  cryptorchidism  func- 
tion may  be  perfect.  Spermatogenesis,  however,  is,  as  a  rule, 
considerabl}^  below  the  normal  in  these  cases. 

When  the  organ  is  so  markedly  misplaced  as  to  cause  discom- 
fort, or  where  a  tendency  to  the  formation  of  hernia  exists,  surgi- 
cal intervention  is  occasionally  desirable.  Under  other  circum- 
stances, however,  except  in  youth,  normal  placement  of  the  organ 
is  usually  unnecessary,  except  when  done  for  cosmetic  purposes, 
and  little  is  to  be  expected  in  the  way  of  increased  functional 
ability. 

Ordinarily  such  conditions  give  rise  to  no  symptoms.  If  a  tes- 
ticle is  retained  in  the  abdomen,  the  differentiation  from  congenital 
absence  of  a  testicle  is  attended  with  difficulty,  and  apparently 
but  little  can  be  done  in  either  instance ;  if  retained  in  the  inguinal 
canal,  it  is  ordinarily  easy  to  feel  and  recognize.  It  is  believed  by 
some  that  retained  testicles  have  a  tendency  to  become  malignant. 
The  treatment  of  the  condition  is  either  negative  or  surgical. 

Hypertrophy  of  the  testicle  is  a  rare  condition,  except  where  it 
occurs  as  a  compensatory  process  in  cases  of  monolateral  congenital 
hypoplasia  or  disease  in  early  youth.  When  the  condition  occurs, 
it  takes  place  by  enlargement  of  the  spermatic  tubules;  it  is 
very  questionable  if  the  true  formation  of  new  tubules  ever  takes 
place. 

Atrophy  of  the  testicle  appears  most  frequently  as  a  result  of 
chronic  inflammatorv  disease  in  which  necrosis  or  loss  of  substance 


PATHOIvOGY   OF   DISEIASES    OF   THE)    TESTICLE 


60 1 


has  taken  place,  with  subsequent  interstitial  hyperplasia  and  a 
normal  retraction  that  takes  place  in  scar  formation.  Atrophy 
may  also  occur  in  marasmus,  extreme  old  age,  and  in  general 
nutritive  disorders  of  pronounced  degree.  Endarteritis  and 
sclerosis  involving  the  nutrient  arteries  of  the  organ  may  also 
cause  atrophy.  Pressure  on  the  spermatic  artery,  as  from  an 
improperly  fitting  truss,  may  occasionally  cause  atrophy. 

The  diagnosis  of  a  marked  degree  of  atrophy  is  simple ;  when  the 
atrophy  is  not  extreme,  it  is  somewhat  more  difficult.  Marked 
atrophy  is  generally  associated  with  loss  of  the  sexual  functions. 
The  treatment  would  necessarily  consist  in  the  treatment  of  causa- 


Fig.  286. — Showing-  the  relations  of  the  testis  and  epididymis  in  acute  orchitis.    T,  T,  Testis ; 
E,  E,  epididymis  ;  A,  sagittal  section  ;  B,  horizontal  section  (Kocher). 


tive  conditions,  together  with  such  local  measures  as  may  be 
most  practical  in  the  particular  instance. 

Fatty  metamorphosis  of  the  testicle  is  occasionally  seen.  In 
this  condition  the  entire  parenchymatous  tissue  may  be  replaced 
by  masses  of  adipose  tissue  or  fat ;  it  is  usually  seen  in  extreme 
old  age  or  in  long-standing  wasting  diseases,  such  as  chronic  tuber- 
culosis or  syphilis. 

A  diagnosis  is  not  usually  easily  made.  It  may  sometimes  be 
suspected  in  men  who  exhibit  an  excessive  amount  of  adipose  tissue 
combined  with  marked  loss  of  sexual  power. 

Acute    Orchitis. — Etioloqy. — Acute    orchitis    occurs    most  fre- 


6o2 


THE    TESTICLE    AND    EPIDIDYMIS 


quently  from  direct  infection  of  the  testicular  substance  by  the 
infectious  processes  of  the  epididymis,  vas  deferens,  or  seminal 
vesicles.  It  is,  therefore,  usually  seen  as  an  accompaniment  or 
sequence  of  urethritis  of  various  types.  True  orchitis  is  much  less 
frequent  than  is  generally  believed,  the  condition  being  often  con- 
founded with  epididymitis. 

It  may  also  arise  in  certain  specific  types  of  general  disease 
with  local  testicular  manifestations.  This  is  particularly  well 
demonstrated  in  mumps,  typhoid  fever,  and  variola. 

Pathologic  Anatomy. — Acute  orchitis  is  usually  manifested  by 
the  occurrence  of  edema,  hyperemia,  and  swelling  of  the  inter- 
stitial   tissues   of   the 
ig  i  '    \  organs,  with  resulting 

compression,  degener- 
ation, and  desquama- 
tion of  the  parenchy- 
matous epithelium. 
The  hyperemia  may 
pass  on  to  a  true  hyper- 
emic  extravasation,  or 
the  leukocytic  infiltra- 
tion may  become  asso- 
ciated with  necrosis 
and  eventually  with 
suppuration.  In  the 
mild  inflammations 
recovery  takes  place 
by  absorption  of  the  inflammatory  exudate,  and  the  degenerated 
epithelium  is  replaced  by  hyperplasia  of  the  normal  remaining 
cells  of  the  spermatic  tubules.  When  absorption  is  incomplete, 
or  in  those  cases  in  which  loss  of  substance  has  taken  place,  inter- 
stitial hyperplasia  occurs,  oftentimes  resulting  in  tubular  atrophy, 
and  the  process  may  become  transformed  in  this  manner  into  one 
of  chronic  orchitis. 

The  symptoms  of  acute  orchitis  are  swelling  of  the  testicle, 
pain  in  the  scrotum  and  loins,  and  general  systemic  disturbances. 
It  is  often  associated  with  acute  urethritis,  following  injury,  and 
also  with  tuberculosis  and  syphilis,  although  the  type  presented 


Fig.  287. — Illustratiiie;  the  relations  of  the  epididymis 
and  testis  in  acute  epididymitis.  In  the  first  figure  the 
head  of  the  epidid>-mis  is  chiefly  affected  and  in  the 
second  figure  the  tail.  T,  T,  Testis  ;  E,  E,  epididymis  ; 
S,  S,  spermatic  cord  (Kocher). 


PATHOLOGY  AND  SYMPTOMS  OF  DISEASES  OF  THE  TESTICLE   603 

in  the  two  last-named  conditions  is  somewhat  different  from  acute 
orchitis  as  ordinarily  seen.  Under  ordinary  circumstances,  within 
two  or  three  weeks  after  its  onset,  resolution  tends  to  take  place 
and  the  swelling  subsides.  It  must  be  differentiated  from  epi- 
didymitis, neoplasms,  hernia,  and  hydrocele.  It  is  not  infre- 
quently associated  with  acute  epididymitis,  and  the  diagnosis 
may  be  reached  by  manipulating  the  swollen  mass,  making 
out  the  lines  of  demarcation  between  the  epididymis  and  the  tes- 


Fig.  288.— Tubercular  orchitis  (natural  size).     From  a  specimen  in  the  Museum  of  Carnegie 

Laboratory. 

tide,  and  finding  the  body  of  the  testicle  proper  swollen  and  tender 
on  pressure.  When  riot  associated  with  acute  epididymitis,  it  is 
comparatively  easy  to  make  out  the  Hue  of  demarcation  between 
the  epididymis  by  its  normal  shape,  and  the  inflamed,  enlarged, 
and  tender  testicle. 

Chronic  orchitis  usually  follows  as  a  direct  sequence  of  the 
acute  type  of  the  disease.  It  may  also  occur  in  chronic  arterial 
affections.     In  either  case  it  is  characterized  by  proliferation  and 


604  THE   TESTICLE    AND   EPIDIDYMIS 

thickening  of  the  interstitium,  with  atrophy  of  the  tubular  ele- 
ments. If  the  disease  progresses,  the  organ  becomes  very  small 
and  hard,  and  is  frequently  the  seat  of  various  forms  of  infiltration, 
particularly  the  calcareous  variety.  Ordinarily  there  are  no 
distinctive  symptoms  associated  with  chronic  orchitis,  and  it  is 
sometimes  difficult  to  diagnose  from  similar  conditions  due  to 
tuberculosis  or  at  times  from  new-growths.  It  may  occur  as  a 
complication  of  mumps,  and  is  believed  to  be  due  at  times  to 
rheumatism  or  malaria,  although  no  cases  have  come  under 
the  writers'  observation  in  which  this  could  be  definitely  demon- 
strated. 

Tubercular  Orchitis. — Tubercular  orchitis  has  its  origin,  as  a 
rule,  in  tubercular  epididymitis.  In  a  considerable  number  of 
cases  it  appears  to  follow  simple  epididymitis  as  a  secondary 
process.  It  apparently  occurs  in  many  cases  as  a  primary  proc- 
ess in  the  epididymis,  the  infection  having  apparently  been 
derived  through  the  lymphatics  or  the  vas  deferens.  Infection 
by  the  blood-vessels  probably  also  occasionally  occurs.  In  some 
cases  the  disease  has  followed  direct  traumatism  to  the  testicle. 
In  these  instances  the  process  probably  develops  in  the  locus 
minora  resistentia,  very  likely  from  organisms  derived  from  a 
quiescent  and  perhaps  unrecognized  lymphatic  lesion. 

As  a  rule,  the  tubercle  formation  is  associated  with  active  growth 
on  the  part  of  the  connective  tissue,  oftentimes  with  pus-formation 
and  extensive  necrosis.  The  process  is  generally  quite  active, 
and  is  not  infrequently  followed  by  general  lymphatic  involve- 
ment, and  particularly  by  a  general  miliary  tuberculosis.  Active 
caseation  is  the  rule,  and  in  relatively  long-standing  cases  calcare- 
ous infiltration  occurs.  In  almost  all  instances  of  tubercular 
orchitis  the  process  eventually  extends  out  into  the  tunica  vagi- 
nalis and  involves  the  scrotum  proper,  causing  induration  and 
ulceration  of  the  skin.  Tubercular  orchitis  may  be  found  asso- 
ciated with  neoplasms.  One  of  the  authors  has  been  recently 
shown  a  case  of  this  nature  by  Dr.  Theodore  Kuhne.  The  pri- 
mary lesion  was  a  tubercular  orchitis  following  a  blow  on  the 
gland  received  while  playing  foot-ball.  Shortly  after  the  injury 
rapid  isolated  growth  took  place  at  the  site  of  the  trauma,  and 
the  nature  of  the  mass  was  most  puzzling  clinically.     Microscopic 


EPIDIDYMITIS 


605 


examination  showed  tuberculosis,  with  the  necrosed  area  infiltrated 
by  spindle-cell  sarcoma.  The  subsequent  history  of  this  case 
showed  the  sarcoma  to  have  originated  in  the  kidney,  with  early 
metastasis  in  the  testis. 

The  symptoms  of  tubercular  orchitis  are  ordinaril}^  pain,  swelling, 
and  ulceration.  In  some  cases  no  manifestations  may  be  present 
except  the  presence  of  tumor  in  the  testicle  proper  or  in  the  epi- 
didymis. When  necrosis  takes  place,  superficial  ulcerations  form. 
The  disease  must  be  differentiated  from  gumma,  maUgnant  disease, 
and  the  after- result  of  simple  orchitis  following  injury  or  gonorrheal 
or  other  infectious  processes.  Under  ordinary  circumstances,  the 
general  systemic  manifestations  of  tuberculosis  are  present  and 
tend  to  make  the  diagnosis  clear.  The  condition  is  sometimes 
associated  with  a  sHght,  brownish-yellow  discharge  from  the 
urethra.  The  occasional  presence  of  tubercle  bacilli  in  such  dis- 
charge confirms  the  diagnosis. 

Syphilitic  Orchitis. — The  testicle  frequently  becomes  the  seat 
of  gummata  in  tertiary  syphilis,  and  not  uncommonly  may  be  so 
diffusely  involved  as  to  present  *a  close  gross  resemblance  to  tu- 
bercular orchitis.  In  secondary  syphilis  intertubular  areas  of  small 
round-cell  infiltration,  often  with  more  or  less  caseation,  are  seen. 

Symptoms. — Ordinarily,  beyond  the  enlargement,  orchitis  due 
to  syphilis  does  not  present  many  symptoms.  Breaking  down  or 
gumma  leads  to  ulcerations,  which  may  be  mistaken  for  tubercular 
ulcerations  or  those  due  to  malignant  disease.  In  such  instances 
the  diagnosis  is  aided  by  observing  the  effect  of  a  vigorous  course 
of  specific  medication.  It  is  very  difficult,  by  means  of  a  physi- 
cal examination  alone,  to  differentiate  between  a  tubercular  infil- 
tration into  the  testicle  and  an  infiltration  due  to  small  gum- 
mata. Gumma  in  its  most  frequent  form  is  very  commonly  con- 
fused with  new-growths,  and  no  case  of  tumor  or  ulcerating  inflam- 
mation of  the  testes  should  be  operated  upon  until  antisyphihtic 
treatment  has  been  tried.  Numerous  cases  have,  in  the  experience 
of  the  authors,  impressively  illustrated  the  wisdom  of  this  step. 

Epididymitis.— This  is  an  inflammatory  condition  of  the  epidid- 
ymis, and  on  account  of  the  great  mass  of  blood-vessels  entering 
into  this  structure,  is  prone  to  be  very  active  in  its  manifestations. 
It  may  be  divided  into  two  forms — acute  and  chronic. 


6o6  THE   TESTICLE    AND   EPIDIDYMIS 

Acute  epididymitis  is  ordinarily  due  to  extension  of  the  inflam- 
mation from  an  acute  urethritis  from  the  posterior  urethra  to  the 
vasa  deferentia  and  to  the  epididymis,  which  becomes  swollen  and 
painful.  This  condition  may  affect  one  or  both  epididymes, 
and  may  develop  at  any  time  in  the  course  of  acute  urethritis. 
Ordinarily  it  may  run  a  course  of  two  or  three  weeks'  duration, 
reaching  its  height  generally  at  the  end  of  the  second  week. 

Symptoms  and  Diagnosis. — Within  two  or  three  days  after  the 
onset  of  the  first  symptoms,  swelling,  pain,  and  general  systemic 
discomfort  develop.  The  pain  extends  upward  along  the  course 
of  the  cord  into  the  groin,  and  occasionally  into  the  abdomen. 
The  pain  may  be  very  intense  in  character  and  associated  with 
general  malaise.  In  the  majority  of  cases  a  slight  rise  in  tempera- 
ture occurs. 

The  differential  diagnosis  from  acute  orchitis  has  previously 
been  mentioned.  In  acute  epididymitis  not  associated  with  acute 
orchitis  the  body  of  the  testicle  proper  can  be  made  out;  it  is 
normal  in  size  and  not  tender  on  pressure,  whereas  the  swollen 
epididymis  is  extremely  painful.  In  acute  epididymitis  the  cord 
is  also  swollen  to  some  extent.  Ordinarily,  at  the  end  of  from  two 
to  three  weeks,  the  acute  symptoms  have  disappeared,  and  more 
or  less  resolution  has  taken  place.  Nodules  of  inflammatory 
infiltration  are  often  left  behind,  absorb  very  slowly,  or  frequently 
exist  throughout  life.  Acute  epididymitis  is  a  common  cause  of 
sterility,  the  inflammatory  products  obstructing  the  canal  of  the 
vas  deferens  or  causing  some  change  either  in  its  expulsive  power 
or  in  the  character  of  the  secretion.  Occasionally,  after  an 
attack  of  acute  epididymitis,  while  undergoing  resolution,  relapses 
occur.  These  relapses  are,  as  a  rule,  more  painful  and  associated 
with  greater  systemic  disturbance  than  accompanied  the  original 
attack. 

Chronic  epididymitis  may  be  diagnosed  only  with  difficulty 
on  physical  examination,  although,  under  ordinar}^  circumstances, 
some  nodules  of  thickening  may  be  detected  either  at  the  head  or 
at  the  tail  of  the  epididymis.  A  history  of  a  previous  acute  at- 
tack of  epididymitis  is  also  given.  The  inflammatory  products 
that  are  present  in  chronic  epididymitis  not  infrequently  serve  as  a 


TORSION    OF   THE    CORD  607 

nidus  or  predisposing  agent  for  the  development  of  tubercular 
disease  of  the  epididymis  or  testicle. 

As  showing  the  necessity  for  the  thorough  and  prolonged  treat- 
ment of  chronic  epididymitis,  so  careful  an  observer  as  Casper 
makes  the  following  statement:  "I  can  state  that  the  majority 
of  childless  marriages  in  which  the  husband  is  at  fault  had  de- 
pended upon  a  double  epididymitis.  It  always  leaves  nodules 
behind,   also  predisposes  to  tuberculosis." 

Torsion  of  the  Cord. — This  is  a  condition  in  which  the  cord  is 
twisted.  It  is  seen  more  often  with  a  retained  testicle,  but  occa- 
sionally with  one  w^hich  has  descended.  As  a  result  of  some  violent 
muscular  effort,  the  testicle  becomes  displaced  and  a  condition 
resembling  an  acute  orchiepididymitis  ensues.  The  diagnosis 
can  generally  be  made  from  the  history  of  the  case,  and  when  the 
inflammatory  condition  admits,  from  the  discovery  of  the  lesion 
on  physical  examination.     The  condition  is  very  rare. 

Treatment. — Cases  should  be  carefully  observed,  and  if  the  in- 
flammatory process  continues  after  simple  measures  have  been 
used,  early  incision  is  advisable,  cleaning  out  of  the  clots, 
straightening,  if  possible,  the  cord,  thus  attempting  to  save  the 
testicle.  This  failing,  testicle  should  be  removed  in  the  manner 
described  in  the  following  chapter. 

Much  more  frequent,  though  still  rare,  is  a  condition  of  orchi- 
epididymitis due  to  strain  set  up  through  violent  muscular  effort, 
in  which  the  cord  has  apparently  been  wrenched,  but  the  testicle 
not  displaced. 

One  of  us  has  had  under  his  care  three  cases  of  this  character, 
and  have  considered  them  as  due  to  a  wrench  of  the  cord.  White 
and  Martin^  have  in  their  work  written  most  exhaustively  and 
interestingly  on  this  and  allied  conditions.  They  have  observed 
twelve  cases,  and  consider  it  due  to  one  of  three  causes:  First, 
contracture  of  the  cremaster  muscle ;  second,  from  rupture  of  the 
veins;  and  third,  from  marked  lesions,  and  they  mention  under 
this  heading,  infection  passing  from  posterior  urethra  along  the 
vas.  The  prognosis  should  be  guarded.  In  one  of  the  cases  occur- 
ring in  the  practice  of  one  of  us  it  was  finally  necessary  to  remove 
the  testicle.  The  treatment  is  similar  to  that  of  torsion  of  the  cord. 
^  "Genito-urinary  Diseases  and  Syphilis,"  Phila.,  1906. 


6o8  THE  TESTICLE   AND  EPIDIDYMIS 

Spermatoceles  are  retention  cysts  of  the  testicle  or  epididymis, 
the  contents  of  which  are  spermatic  fluid.  They  are  ordinarily 
of  slow  growth,  have  the  appearance  and  characteristics  of  cysts, 
and  sometimes  cause  pain  if  congestion  of  the  organs  exists.  They 
may  be  congenital  or  may  be  due  to  trauma.  Although  not 
infrequently  reported,  judging  from  our  clinical  and  pathologic 
experience,  such  cysts  are  quite  unusual. 

Treatment. — Enucleation  of  the  sac. 

Tumors  of  the  Testicle. — According  to  some  authors,  tumors 
of  the  testicle  are  rare;  in  the  writers'  experience,  however, 
they  are  not  uncommon.  Not  infrequently  they  are  confused 
with  various  forms  of  orchitis,  notably  with  the  tubercular  and 
syphilitic  varieties.  Even  after  removal  of  the  tumors  their  gross 
appearance  is  very  often  misinterpreted  by  surgeons  of  wide  ex- 
perience. It  is,  therefore,  essential  that  a  microscopic  examination 
of  the  tissues  be  made  before  an  absolute  differential  diagnosis 
is  made  between  new-growths  of  the  testicle  and  orchitis — particu- 
larly the  tubercular,  syphilitic,  or  actinomycotic  forms.  For- 
tunately, the  treatment  in  all  cases,  with  the  exception  of  the  syphil- 
itic, is  practically  the  same ;  and  clinically  a  course  of  mercury  and 
the  iodids  is  prescribed  as  a  matter  of  routine  in  most  cases  of  tes- 
ticular growth  before  operative  measures  are  adopted.  In  many 
cases,  particularly  when  erosion  of  the  scrotum  has  taken  place,  ma- 
terial may  be  conveniently  secured  for  microscopic  examination, 
and  this  should  be  done  whenever  possible.  The  writers  do  not, 
however,  advocate  the  practice  of  cutting  through  the  intact  scro- 
tum into  a  tumor  of  the  testicle  for  the  sole  purpose  of  securing 
material  for  microscopic  examination,  for  they  believe  that  in  a 
certain  number  of  cases  this  procedure  tends  to  favor  dissemination 
and  the  early  production  of  metastases.  On  the  other  hand,  par- 
ticularly when  both  testicles  are  involved,  it  is  excellent  practice  to 
prepare  the  case  for  operation, — that  is,  for  castration, — and,  in  the 
course  of  the  operation,  to  select  and  remove  a  segment  of  tissue, 
submitting  it  to  immediate  examination  by  the  frozen  section 
method,  so  that  the  proper  treatment  may  at  once  be  decided  on 
and  dangerous  delays  avoided.  The  writers  have  seen  several 
cases  in  which  serious  errors  resulted  from  the  disregard  of  this 
simple  precaution. 


TUMORS    OI'    THE   TESTICLE  609 

Tumors  of  the  testicle,  excluding,  of  course,  those  of  purely 
inflammatory  origin,  may  be  conveniently  divided  into  three 
classes :  the  cystic,  the  benign,  and  the  malignant. 

Cystic  Tumors  of  the  Testicle. — Retention  cysts  of  the  testicle 
usually  occur  as  the  result  of  localized  areas  of  inflammatory  dis- 
ease that  cause  occlusion  of  one  or  more  of  the  excretory  tubules, 
either  in  the  body  of  the  testicle  or,  more  frequently,  in  the  rete 
or  tubuli  efferenti.  Cysts  thus  formed  commonly  contain  a  more 
or  less  turbid,  milky  fluid,  in  which  the  presence  of  spermatozoa  and 
broken-down  epithelial  cells  may  be  demonstrated.  Occasionally, 
particularly  in  long-standing  cases,  the  cysts  may  contain  a  clear 
serum,  and  be  separated  from  the  surrounding  structures  by  well- 
defined  capsules  of  connective  tissue.  In  a  certain  number  of 
cases  these  retention  cysts  may  be  multiple  and  may  closely  simu- 
late colloid  carcinoma  or  other  forms  of  malignant  disease. 

Papillomatous  adenocystomata  are  benign  growths  involving 
the  testicle  somewhat  rarely,  and  characterized  by  the  formation 
of  cystic  cavities  Hned  by  columnar  epithelium,  which,  being  in 
an  active  state 'of  proliferation,  may  grow  into  the  cavity  of  the 
cysts,  eventually  filling  them  with  friable  masses  of  proliferating 
cells.  These  tumors  possess,  in  general,  many  of  the  character- 
istics of  the  papillary  adenocystoma  of  the  ovary,  and,  like 
these  growi:hs,  are  prone  eventually  to  become  malignant  and  to 
set  up  metastases,  particularly  by  direct  transmission.  It  seems 
probable  that  these  cystic  tumors  may  eventuate  from  the  reten- 
tion cysts  previously  described,  or  perhaps  from  persistent  rem- 
nants of  Miiller's  canal. 

Dermoid  cysts  of  the  testicle  are  rare,  and  are  relatively  very 
much  less  frequent  than  a  similar  growth  found  rather  commonly 
in  the  ovary.  As  a  rule,  gross  examination  is  all  that  is  required 
for  their  identification. 

Parasitic  cystic  tumors  of  the  testicle  are  very  rare  in  this  country, 
although  one  occasionally  encounters  echinococcus  cysts  of  the 
testicle,  most  often,  however,  in  foreigners,  and  even  then  with 
great  infrequency. 

Benign  Tumors  of  the  Testicle. — The  benign  tumors  of  the 
testicle  are  fibroma,  chondroma,  osteoma,  and  adenoma.  Of 
these,  the  chondroma  is,  in  the  writers'  experience,  seen  most 
frequently.  • 

39 


6lO  THE    TESTICLE    AND    EPIDIDYMIS 

Fibromata  are  usually  found  originating  from  the  tunica  vagi- 
nalis, from  the  tissue  of  the  albuginea,  or  in  the  rete  testis.  They 
are  generally  small  and,  as  a  rule,  cause  but  Httle  or  no  dis- 
turbance. 

Testicular  chondroma  may  arise  in  anv  part  of  the  organ,  and 
may  attain  considerable  size.  These  tumors  are  verv  prone  to  be 
associated  either  with  carcinomatous  or,  more  frequently,  with 
sarcomatous  growths.  Though  innocent  in  immediate  nature, 
they  should  always  be  removed. 

Osteomata  are  most  commonly  found  associated  with  the  carti- 
laginous tumors  or  with  the  m^ocoma. 

True  adenoma  of  the  testicle  is  of  rare  occurrence.  Adenoma 
is  commonly  found  associated  with  carcinomatous  growths  of  the 
organ,  and  since  all  adenomata  are  very  prone, to  become  malignant 
if  allowed  to  remain,  they  should  be  removed. 

Of  the  malignant  tumors  of  the  testicle,  sarcomata  have  most 
frequently  come  under  the  writers'  observation.  As  a  rule,  these 
tumors  presented  lesser  degrees  of  malignancy,  occurring  as  fibro- 
sarcoma or  chondrosarcoma.  Early  removal  generally  warrants 
a  better  prognosis  than  in  most  cases  of  sarcoma  occurring  else- 
where. Sarcomata  are  very  commonly  confused  clinically  with 
tuberculosis  and  syphilis  of  the  testicle,  which  they  strongly  re- 
semble in  their  gross  anatomic  appearance. 

Primary  carcinoma  of  the  testicle  is  somewhat  rare,  although 
carcinomatous  invasion  from  an  epithelioma  of  the  scrotum,  com- 
monly known  as  "chimney-sweep's  cancer,"  is  relatively  frequent. 
The  prognosis  in  carcinoma  of  the  testicle  is  less  favorable  than  in 
sarcoma,  owing  to  the  abundant  lymphatic  supply  and  to  infec- 
tion of  the  inguinal  lymph-nodes,  which  commonly  results  early 
in  the  progress  of  the  disease. 

Of  the  more  unusual  forms  of  malignant  tumors  of  the  testicle, 
the  writers  have  seen  several  cases  of  hypernephroma  and  endothe- 
lioma. On  account  of  the  great  variety  of  these  tumors,  how- 
ever, and  the  fact  that  their  treatment  is  similar  to  that  demanded 
in  sarcoma  and  carcinoma,  a  more  detailed  description  is  not  war- 
ranted. 

Varicocele. — This  condition  consists  of  an  enlargement  of  the 
veins  and  cords  in  the  pampiniform  plexus.     The  diagnosis  is 


hydrocele; 


6ii 


easily  made  by  feeling  the  mass,  a  sensation  being  imparted  to 
the  touch  as  if  a  bunch  of  thick  worsted  were  grasped.  A'aricocele 
gives  rise  to  very  few  symptoms,  although  it  is  believed  to  cause 
occasional  attacks  of  nuralgia  in  the  scrotal  region.  Beyond  the 
appHcation  of  a  suspensory  bandage,  no  treatment  is  required. 
When,  however,  the  enlargement  is  very  extensive,  the  mass  being 
equal  to  or  larger  than  the  corresponding  testis,  operative  proce- 


Fig.  289. — Bilateral  hydrocele  (Frisch  and  Zuckerkandl). 

dure  is  called  for.     For  a  further  consideration  of  the  subject,  see 
the  chapter  ofi  the  Treatment  of  Diseases  of  the  Testicle. 

Hydrocele. — Hydrocele  of  the  cord,  which  is  quite  common,  is 
almost  invariably  a  localized  condition,  giving  rise  to  the  formation 
of  cystic  tumors  in  the  cord,  ordinarily  of  the  size  of  a  large  marble, 
and  filled  by  a  clear  serous  fluid.  Care  should  be  taken  that 
these  tumors  are  not  mistaken  for  hernia,  which  they  sometimes 
resemble,  and  from  which  they  can  be  differentiated  by  the  fact 
that  the  hernial  pouch  can  be  usually  returned  to  the  abdominal 


6l2  THE    TESTICLE    AND    EPIDIDYMIS 

cavity,  the  patient  lying  on  the  back  and  the  pouch  being  pressed 
upward;  in  hydrocele  the  mass  cannot  be  thus  returned. 

In  hydrocele  there  is  an  accumulation  of  fluid  in  the  tunica 
vaginalis  testis;  the  condition  can  be  diagnosed  by  inserting  a 
hypodermatic  needle  into  the  mass,  when,  if  hydrocele  is  present, 
a  clear,  slightly  yellow  fluid  will  escape  from  the  needle  or  can  be 
withdrawn.  Besides  hernia,  the  only  other  condition  that  at  all 
resembles  hydrocele  is  supernumerary  testicle. 

The  ordinary  hydrocele  is  an  accumulation,  in  the  serous  sac  of 
the  testicle,  of  fluid  resulting  from  some  change  that  takes  place 
in  the  walls  lining  the  tunica  vaginalis  testis.  The  nature  of  the 
pathologic  change  is  not  well  understood.  The  accumulation 
gives  rise  to  a  pear-shaped  swelling  in  the  scrotum.  Generally, 
the  condition  is  unilateral,  but  double  hydrocele  of  the  tunica 
vaginalis  is  not  very  uncommon.  The  latter  gives  rise  to  a  pear- 
shaped  swelling  involving  the  entire  scrotum;  this  swelling  is  at 
times  enormous;  the  sac  will  occasionally  hold  a  pint  or  more  of 
fluid. 

The  diagnosis  is  easily  made  from  the  shape  of  the  swelling  and 
from  the  characteristic  resistance  on  palpation ;  it  can  be  confirmed 
by  introducing  a  hypodermatic  needle  and  examining  any  fluid  that 
may  escape.  It  is  unattended  with  any  inflammatory  reaction, 
and  does  not,  ordinarily,  give  rise  to  pain.  It  more  commonly 
attacks  the  young,  in  which  case  tuberculosis  sometimes  plays  a 
part,  or  the  condition  may  be  congenital.  It  is  also  very  fre- 
quently found  in  later  life,  often  associated  with  some  change  in 
the  prostate  or  walls  of  the  bladder.  Hydrocele  is  in  all  proba- 
bility temporarily  associated  with  attacks  of  acute  epididymitis  or 
orchitis,  and  ordinarily,  in  such  cases,  subsides  without  special 
treatment. 

Tapping  is  a  conservative  measure. 

The  term  acute  hydrocele  has  been  applied  to  represent  the 
accumulation  of  fluid  in  the  tunica  vaginalis  which  accornpanies 
the  acute  inflammatory  condition  of  the  testicle  or  the  epididy- 
mis just  mentioned,  while  chronic  hydrocele  is  applied  to  the 
more  ordinary  condition,  of  which  we  treat  in  detail.  It  is 
customary,  in  addition  to  the  other  measures,  to  diagnose  the 
various  forms  of  hydrocele  by  the  so-called  light  test,  which  con- 


ELEPHANTIASIS   OF   THE    SCROTUM  613 

sists  in  a  light  being  placed  on  one  side  of  the  sac,  the  tumor 
coming  between  the  light  and  the  eye  of  the  observer,  these  sacs 
being  translucent. 

There  are,  in  addition,  several  forms  of  congenital  hydrocele 
caused  by  some  communication  between  the  tunica  and  the 
abdominal  cavity,  or  due  to  retention  of  some  of  the  fetal  tissues. 
They  are  comparatively  rare  and  easy  to  destroy,  their  diagnosis 
presenting  no  great  difficulty,  and  they  should  be  treated  as  hydro- 
cele of  the  cord. 

Multilocular  Cysts.— Although  they  occur  probably  but 
seldom,  occasionally  multilocular  cysts  are  met  with  forming 
a  hydrocele.  We  have  operated  on  one  such  case.  They  can 
be  diagnosed  before  operation,  which  is  probably  rarely  done,  if 
on  aspiration  only  a  small  amount  of  fluid  comes  away  without 
complete  reduction  of  the  sac.  The  treatment  should  be  that  of 
ordinary  hydrocele. 

Hematoma  of  the  Cord. — ^In  this  condition  a  tumor  is  present 
in  the  cord  which  may  be  encysted  or  may  extend  well  along  the 
length  of  the  cord.  It  is  due  to  and  made  up  of  an  infiltration  of 
blood  from  the  blood-vessels.  These  tumors  are  caused  by  an 
injury  to  the  cord  of  some  character.  The  diagnosis  is  easy  from 
the  history  of  the  case,  the  presence  of  a  hard,  non-translucent 
tumor,  which  does  not  involve  the  testicle  or  the  epididymis, 
and  which  is  not  reduced  when  the  patient  is  in  a  reclining  posi- 
tion, as  would  be  the  case  if  a  hernia  were  present. 

The  treatment  is  to  open  the  tumor.  If  possible,  remove  any 
cystic  wall  present.  The  infiltration  may  be  so  diffuse,  as  in  the 
case  treated  by  one  of  us,  that  this  procedure  cannot  be  carried 
out.  Scraping  out  the  infiltrated  material,  however,  is  eventually 
followed  by  a  gradual  absorption  of  any  thickening  that  may 
remain  in  the  cord. 

ELEPHANTIASIS  OF  THE  SCROTUM 

Elephantiasis  of  the  scrotum  is  due  to  some  defect  in  the  circu- 
lation through  the  lymph-canals,  such  as  might  result  from  the 
formation  of  cicatricial  tissue  following  an  operation  or  a  wound 
of  the  scrotum,  or  it  may  be  due  to  pressure  of  the  Filaria  san- 
guinis hominis. 

This  subject  is  becoming  of  such  importance  that  it  has  been 


6i4 


THE    TESTICLE   AND    EPIDIDYMIS 


thought  advisable  to  rewrite  the  article  from  our  previous  edition 
and  to  consider  it  more  in  detail.  Curiously  enough,  most  of  the 
information  obtainable  comes  from  French  sources,  probably  owing 
to  the  tendency  of  South  Americans  to  visit  France  in  the  past  and 
consult  surgeons  there.  Since  the  Spanish  War  cases  of  filaria  are 
seen  more  and  more  frequently  in  this  country.  A  very  good  article 
has  recently  been  written  on  this  topic  in  the  "Malades  des  Organs 
Genito  de  I'Hommes,"  by  A.  Dentu  and  P.  Delbet,  Paris,  19 16. 


Fig.  290. — Filaria  of  testicle  (after  Dentu  and  Delbet). 

The  organism  is  found  in  the  blood,  into  which  it  apparently 
journeys  from  the  lymphatic  system.  It  appears  during  sleep,  and 
is  naturally  to  be  found  about  midnight.  Its  marked  character- 
istic is  to  attack  the  lymphatic  system,  particularly  the  lymphatics 
of  the  scrotum  and  of  the  cord,  the  tunica,  and  the  testicle.  It  is 
perhaps  carried  by  means  of  mosquitoes,  as  is  the  malaria  Plas- 
modia, and  the  old  ideas  concerning  its  infestion  of  the  system 
from  water  and  entrance  through  various  orifices  through  bathing 
are  probably  incorrect. 

As  regards  its  general  treatment,  quinin,  arsenic,  salvarsan,  and 
generally  the  various  malarial  antidotes  are  useful.     General  ig- 


ELEPHANTIASIS    OF   THE    SCROTUM  615 

norance  seems  to  prevail,  particularly  in  this  country,  with  regard 
to  the  frequency  of  its  occurrence.  It  is  found  in  India,  it  is  so 
stated,  and,  what  is  of  particular  interest  to  us,  it  is  found  with  very 
great  frequency  in  certain  parts  of  South  America,  including  the 
West  Indian  Islands. 

In  the  article  above  referred  to  it  is  stated  that  50  per  cent,  of 
the  inhabitants  of  the  island  of  Guadeloupe  are  infected  with  filaria. 
Our  personal  observations  would  seem  to  show  us  that  a  small 
proportion  of  the  inhabitants  of  Porto  Rico  suffer  from  the  effects 
of  this  disease. 

Probably  the  most  effective  of  all  treatment  is  removal  to  a  colder 
climate.  It  seems  to  be  the  consensus  of  opinion  of  the  suft'erers 
from  this  disease  that  the  parasite  does  not  develop  in  a  cold  clim- 
ate, although  it  may  not  be  entirely  eradicated  and  may  lie  dor- 
mant and  give  rise  to  acute  exacerbations  on  returning  to  the 
source  of  the  original  infection.  It  is  particularly  prone  to  attack, 
as  previously  stated,  the  lymphatics,  either  genital  or  perigenital, 
in  the  latter  case  giving  rise  to  such  conditions  as  varicosity  of  the 
lymphatics  in  the  buttocks.  It  probably  acts  by  causing  a  chronic 
inflammatory  condition,  or  else  its  effects  are  due  to  mechanical 
blocking  of  the  lymphatic  system.  When  its  lesions  first  appear 
there  may  be  a  sudden  onset  attended  with  chill  and  fever,  or  the 
symptoms  may  develop  insidiously;  it  may  cause  a  hydrocele  con- 
taining milky  fluid;  it  may,  probably  indirectly  acting  in  some  way 
from  pressure,  cause  hydrocele  with  the  ordinary  clear  fluid  in 
which  the  filaria  cannot  be  discovered,  as  in  a  case  operated  on  b}^ 
one  of  us.  It  may  cause  a  hydrocele  of  the  cord  resembling  some 
other  tumor  of  the  cord  and  may  cause  such  a  distention  of  the 
inguinal  lymphatic  as  to  resemble  a  hernia. 

It  is  extremely  prone  to  cause  epididymitis  and  orchitis,  either  of 
an  acute  or  subacute  character.  The  general  appearance  of  these 
lesions  is  very  well  shown  in  the  illustration  presented,  and  is 
similar  to  what  have  been  seen  by  the  authors  at  operation.  It 
is  best  known  as  being  the  principal  cause  of  elephantiasis. 

The  diagnosis  depends  to  a  considerable  extent  about  the 
occurrence  of  the  filaria  in  the  neighborhood.  As  previously  stated 
it  is  at  times  difficult  to  demonstrate  in  the  blood,  although  this 
is  the  only  certain  means  of  diagnosis.     Generally  speaking,  the 


6l6  THE   TESTICLE   AND    EPIDIDYMIS 

lesions  are  fairly  characteristic,  as  the  infiltrated  tissues  are  made 
up  of  characteristically  dilated  or  inflamed  lymphatic  tissues  and 
channels.  It  is  difficult  to  differentiate  between  such  changes  and 
those  due  to  simple  inflammatory  processes. 

The  treatment  of  the  changes  caused  by  filaria  is  essentially  sur- 
gical. The  operative  procedures  should  be  similar  in  character  to 
those  instituted  for  similar  conditions  due  to  any  cause.  The  tes- 
ticles may  be  so  embedded  in  the  tissues  that  the}^  may  be  hard 
to  separate,  and  in  such  cases  the  cord  should  be  used  as  a  guide. 
In  operations  for  elephantiasis,  even  when  this  condition  is  due  to 
other  causes  than  that  of  filaria,  a  partial  operation  may  be  of 
aid  when  it  is  impossible  owing  to  the  amount  of  involved  tissue 
to  do  a  complete  one.  There  may  be  such  an  invasion  of  the  skin 
surrounding  the  neighboring  organs  that  further  plastic  opera- 
tions may  be  necessary  to  fill  in  the  surfaces  from  which  the  skin 
has  been  removed.  This  subject  is  again  considered  in  the  section 
on  "The  Surgery  of  the  Testicle  and  its  Covering." 

The  prognosis  in  some  of  the  conditions  caused  by  filaria,  par- 
ticularly those  around  the  testicle  and  the  epididymis,  would  seem 
to  be  better  than  when  it  is  performed  for  similar  conditions  due 
to  other  causes.  An  operation,  though. not  absolutely  complete, 
seems  to  have  a  tendency  to  stimulate  the  normal  functions  of  the 
system  to  overcome  the  disease.  This  is  our  opinion  as  arrived  at 
from  a  consideration  of  the  literature  on  the  subject,  and  from  re- 
ports of  cases  made  to  us  personally,  and  from  the  limited  oppor- 
tunities we  have  had  of  observing  the  after-effect  of  surgical  treat- 
ment in  these  diseases.  It  is  particularly  urged  that  as  much  of 
the  testicle  be  left  behind  as  possible,  even  when  it  is  apparently 
wholly  diseased,  not  only  for  its  cosmetic  effect,  but  apparently 
from  the  unusual  energy  which  nature  seems  to  display  in  throwing 
off  diseased  conditions  when  due  to  this  organism,  after  these  con- 
ditions have  once  been  attacked  surgically.  The  prognosis  should, 
however,  always  be  guarded  as  to  a  recurrence  of  the  condition  if 
the  infection  cannot  be  eliminated. 


CHAPTER  XXIX 
THE  TREATMENT  OF  DISEASES  OF  THE  TESTICLE 

THERAPEUTIC  MEASURES 

But  little  need  be  said  regarding  the  medical  treatment  of  dis- 
eases of  the  testicles.  These  affections  are,  however,  so  common 
that  the  general  practitioner  should  have  a  good  understanding 
of  the  surgical  treatment  of  these  diseases,  and  the  surgeon  should 
have  a  clear  knowledge  of  the  various  procedures  that  should  be 
adopted  before  surgical  interference  is  resorted  to.  When  the  lat- 
ter is  indicated,  it  usually  is  necessarily  radical. 

It  should  be  borne  in  mind  that  the  testicle  and  its  covering  are 
particularly  prone  to  be  the  seat  of  tertiary  syphilitic  deposits. 
The  writers  have  seen  them  in  persons  who  gave  no  history  of  the 
presence  of  primary  or  secondary  lesions.  These  syphilitic  de- 
posits, as  is  well  known,  disappear  rapidly  under  syphilitic  medica- 
tion. In  a  doubtful  case,  where  the  testicle  or  the  epididymis  is 
greatly  enlarged,  it  is  well  to  give  full  doses  of  mixed  treatment  or  of 
potassium  iodid,  in  addition  to  which  applications  of  a  mercurial 
ointment  may  be  employed  or  mercurial  inunctions  may  be  applied 
to  other  portions  of  the  body  than  the  testicle,  and  the  scrotum 
anointed  with  iodin-vasogen,  which  should  be  well  rubbed  in. 

Repeated  attacks  of  epididymitis  or  orchitis  without  apparent 
cause  should  give  rise  to  the  suspicion  of  syphilis  being  a  factor 
in  the  case.  The  medicinal  treatment  of  the  most  common  forms 
of  testicular  inflammatory  conditions,  viz.,  epididymitis  or  orchitis 
of  gonorrheal  origin,  should  be  divided  into  two  classes — one 
having  a  direct  effect  on  the  testicular  inflammation,  and  the  other 
on  the  system  generally.  Of  the  first  class  of  remedies,  the  tincture 
of  Pulsatilla  apparently  exerts  a  benign  influence,  given  early  in 
the  attack  in  drop  doses  repeated  hourly — ten  or  twelve  times  in 
twenty -four  hours.  The  second  class  of  remedies  consists  of  tonics 
containing  iron  and  quinin,  which  are  of  great  value  in  these  con- 
ditions for  the  purpose  of  maintaining  or  improving  the  general 

617 


6l8  TREATMENT   OF   DISEASES   OF   THE   TESTICLE 

health.  Very  rarely  in  an  attack  of  epididymitis,  particularly 
in  relapsing  cases,  the  pain  is  so  severe  that  morphin  hypoderma- 
tically  is  necessary  for  its  relief. 

The  tendency  of  tuberculosis  to  attack  the  testicle  should  always 
be  borne  in  mind.  Occasionally  this  is  the  only  organ  in  which 
the  disease  makes  itself  manifest.  Acquired  hydrocele,  especially 
in  young  persons,  is  apt  to  be  of  tuberculous  origin.  In  addi- 
tion, small  deposits  of  inflammatory  products  caused  by  tubercu- 
losis— so  small  as  hardly  to  be  perceptible — are  not  infrequently 
to  be  found  in  the  testicle  or  the  epididymis.  It  is  interesting 
to  observe,  in  these  cases,  how  a  slight  injury  will  cause  these 
tuberculous  products,  which  may  lie  dormant  for  months  and  years, 
to  serve  as  the  starting-point  of  an  inflammation  involving  the 
testicle  and  the  epididymis.  Of  three  cases  of  this  type  en- 
countered, who  gave  a  history  of  the  same  slight  injury, — slipping 
without  falling  on  the  pavement, — in  two  there  was  no  history  of 
gonorrheal  infection;  in  the  third,  some  twenty  years  had  elapsed 
since  gonorrheal  manifestations  had  presented  themselves;  in 
the  three  cases  each  developed  an  acute  orchi  -  epididymitis. 
In  the  first  two  of  these  cases  the  inflammatory  symptoms  dis- 
appeared in  a  few  days  under  rest  and  the  application  of  a 
lead-and-opium  wash.  In  the  third  case,  because  of  the  good  re~ 
suits  obtained  in  the  first  two  cases,  a  very  favorable  prognosis 
was  given.  In  spite  of  similar  treatment,  however,  pus  rapidly 
developed;  this  was  evacuated  and  the  cavity  cleaned  out, 
but  in  from  twenty-four  to. forty-eight  hours  the  remainder  of  the 
testicle  had  become  so  completely  disorganized  that  removal  was 
imperative. 

The  three  cases  just  described  are  good  examples  of  what  is  to 
be  expected  from  tuberculous  invasion  all  along  the  urinary  tract. 
Not  even  an  experienced  observer  can  prognosticate  what  the  out- 
come will  be  or  whether  or  not  an  operation  will  be  necessary. 
The  prostate  and  seminal  vesicles,  when  involved  in  tuberculous 
processes,  are  apparently  not  quite  so  likely  to  cause  serious  sys- 
temic manifestations. 

In  making  a  diagnosis  of  any  given  obscure  case,  the  practitioner 
should  carefully  examine  the  testicle  for  evidences  of  tuberculosis  or 
syphilis ;  frequently  the  only  lesions  of  these  diseases  that  can  be 


THERAPEUTIC    MEASURES 


619 


well  marked  out  are  found  here.  Internal  medication  other  than 
that  indicated  for  the  disease  itself  is  of  no  apparent  benefit  in  the 
treatment  of  tuberculosis  of  the  testicle  or  its  covering. 

As  regards  external  measures  for  the  relief  of  acute  inflammatory 
conditions  of  the  testicle,  such  as  acute  orchitis  and  acute  epididy- 
mitis, rest  in  bed,  when  it  can  be  secured,  is  imperative.  While 
resting,  the  testicles  should  be  supported  on  a  bridge  placed  be- 
tween the  legs,  running  across  under  the  legs  just  anterior  to  the 
scrotum.     This  bridge  may  be  constructed  of  a  towel  passed  around 


Fig.  291. — Showing  "  bridge  "  for  support  of  scrotum  in  epididymitis. 


the  legs  or  of  adhesive  plaster.  In  these  acute  inflammations  the 
ordinary  local  appUcations,  such  as  are  used  for  similar  conditions 
occurring  elsewhere  in  the  body,  are  indicated.  Generally  they 
consist  of  either  heat  or  cold,  using  that  which  gives  the  most  relief. 
There  is  some  danger  of  sloughing  following  the  too  prolonged 
use  of  the  ice-bag,  and  for  this  reason  it  is  safer  to  employ  heat. 
Lead-and-opium  wash,  appHed  on  bits  of  gauze,  as  hot  as  can  be 
borne,  changing  as  often  as  it  becomes  cool,  is,  in  the  writers' 
experience,  productive  of  much  comfort,  and  is  to  be  advised  when 


620 


TREATMENT   OF   DISEASES  OF  THE   TESTICLE 


the  services  of  a  constant  attendant  can  be  obtained.  An  applica- 
tion consisting  of  opium  and  belladonna  ointments,  equal  parts, 
is  serviceable.  These  ointments  may  be  applied  on  a  piece  of  lint, 
over  which  an  oiled  silk  dressing  should  be  placed,  retained  in 
position  by  a  suspensory  bandage.  When  the  acute  process  has 
somewhat  subsided,  ordinarily  in  a  few  days,  which  is  generally 
evidenced  by  a  diminution  of  pain,  even  when  the  swelling  re- 
mains, patients  may  be  allowed  to  sit  up,  but  should  be  cautioned 
against  moving  about  for  a  few  days,  because  of  the  danger  of 
relapse.  The  applications  previously  advised  may  be  continued, 
or  a  ID  per  cent,  ichthyol  ointment  may  be  used ;  or,  if  desired,  the 
scrotum  may  be  painted  with    lo  per  cent,   guaiacol  diluted  in 

alcohol,  or  with  a  solution  of 
silver  nitrate,  40  or  60  grains 
to  the  ounce.  When  the  acute 
inflammatory   processes,  such 

A*  A! BfrB' 


A 

B' 

\ 

\ 

/ 

\. 

/ 

•' 

.'' 

y' 

"\ 

/ 

\^ 

ii 

A' 

Fig.  292. — Bandage  for  scrotum. 


as  are  associated  with  epididymitis  or  orchitis,  have  disappeared, 
small  foci  of  inflammatory  products  will  very  often  be  found  re- 
maining in  the  testicle  or  epididymis.  In  order  to  secure  the  best 
results,  local  applications  to  the  scrotum  in  the  region  of  such  foci 
should  be  made  for  many  weeks  and  months.  A  10  per  cent,  oint- 
ment of  lead  iodid  may  be  used,  or  the  iodin-vasogen  may  be  applied 
daily.  When  such  conditions  are  believed  to  be  tuberculous, 
vasogen  and  guaiacol  may  be  used;  if  syphilitic  origin  is  sus- 
pected, a  5  per  cent,  ammoniated  mercury  ointment  may  be  ap- 
plied. It  is  hardly  necessary  to  mention  the  necessity  of  institut- 
ing proper  constitutional  and  hygienic  treatment,  as  well  as 
local  measures  for  the  relief  of  any  lesions  of  the  urethra  that 
may  exist. 


OPERATION    FOR   HYDROCELE 


621 


SURGERY   OF   THE    TESTICLE   AND   ITS   COVERING 
In  considering  the  surgical  treatment  of  diseases  of  the  testicle, 
the  operative  procedures  for  the  relief  of  diseased  conditions  of  the 
covering  of  the  testicle  come  first  in  order.     Of  these,  hydrocele 
is  the  most  common. 


Fig.  293. — Bandage  for  scrotum. 


Operation  for  Hydrocele 
This,  as  has  been  said,  is  a  very  common  affection;    it  may 
involve  the  entire  tunica  or  only  a  portion;    it  may  be  lobulated. 
Hydrocele,  which   may   involve    the    covering   of    one    or    both 


622 


TREATMEXT    OF    DISEASES    OF    THE    TESTICLE 


testicles,  and  which  is  seen  in  both  the  young  and  the  old,  is  so 
frequently  met  that  many  attempts  have  been  made  to  devise  an 
ideal  operation  for  its  cure,  but  thus  far  these  attempts  have  been 
futile.  The  simplest  operation  for  the  relief  of  hydrocele  is  that 
which  consists  of  tapping  by  means  of  a  trocar ;  this  is  an  operation 
that  almost  every  practitioner  is  called  upon  to  perform  at  some 


Fig.  294. — Tapping  a  hydrocele. 

time.  Even  in  this  simple  operation,  however,  proper  attention 
must  be  given  to  details  in  order  to  secure  the  best  results.  When 
possible,  in  tapping  a  hydrocele,  it  is  well  to  have  the  services  of  an 
assistant.  After  aseptic  precautions  have  been  observed,  the  assis- 
tant locates  the  testicle  in  the  mass,  holding  it  with  one  hand, 
and  making  the  bag  of  fluid  protrude  in  such  a  manner  as  to  render 
it  as  tense  as  possible.     The  surgeon  then  selects  the  most  promi- 


OPERATION   FOR   HYDROCELE  623 

nent  part  of  the  bulging  mass,  washes  it  with  some  aintiseptic 
solution,  and  sprays  the  point  where  it  is  purposed  to  introduce 
the  trocar  with  ethyl  chlorid;  the  smallest  trocar  that  it  is  prac- 
ticable to  use,  which  should  be  sharp  and  sterile,  should  be  plunged 
quickly  and  deeply  through  the  covering  of  the  testicle  into  the 
sac,  and  the  fluid  allowed  to  escape  into  a  proper  receptacle. 
After  the  fluid  has  escaped,  the  surrounding  areas  should  be  sub- 
mitted to  a  sort  of  milking  process,  in  order  to  be  certain  that  no 
fluid  has  been  left  behind  in  the  folds  of  the  tunica;  the  trocar 
should  then  be  quickly  withdrawn  and  a  strip  of  adhesive  plaster 
placed  over  the  site  of  the  puncture.  Occasionally,  even  in  the 
hands  of  an  experienced  operator,  particularly^  when  the  services 
of  an  assistant  are  not  to  be  had  and  when  the  walls  of  the  sac 
have  become  very  much  thickened,  the  testicle  is  wounded  by 
the  trocar.  As  a  rule,  beyond  the  pain  it  causes,  no  particular 
harmful  results  follow  this  accident. 

It  has  been  a  common  custom  for  a  great  many  years  to  inject 
into  the  sac,  through  the  trocar,  a  few  drops  of  a  powerful  de- 
structive agent,  with  the  object  of  setting  up  an  adhesive  inflam- 
mation between  the  walls  of  the  tunica  that  will  cause  them  to 
adhere  and  thus  prevent  the  reformation  of  fluid.  This  method 
is  sometimes  successful.  The  fluid  most  generally  used  for  the 
purpose  is  phenol ;  not  more  than  five  or  ten  drops  of  95  per  cent, 
pure  phenol  should  be  used.  A  few  drops  of  a  strong  solution  of 
iodin  may  be  employed.  The  reaction  following  this  procedure 
is  generally  marked.  For  several  days  swelling  and  pain  are 
severe,  but  gradually  subside,  and,  in  fortunate  cases,  the  fluid 
does  not  return. 

Personally,  the  writers  prefer  one  of  the  radical  operations, 
three  of  which  are  at  the  present  time  in  use.  The  old  opera- 
tion consists  in  making  a  lengthy  incision  through  the  skin 
down  to  the  tunica,  carefully  dissecting  away  the  tissues  on  each 
side,  and  tying  off  any  bleeding  points ;  when  the  tunica  is  reached, 
it  is  a  good  plan  to  hook  it  before  puncturing  the  sac  with  a  knife, 
for,  simple  as  the  procedure  is,  it  is  sometimes  difficult,  if  the  sac 
is  punctured  too  soon  and  the  fluid  suddenly  escapes,  to  map  out 
and  bring  into  the  field  of  vision  the  proper  walls  of  the  sac.  The 
sac  having  been  hooked,  it  can  then  be  punctured  and  a  small 


624 


TREATMENT   OF   DISEASES   OF   THE    TESTICLE 


artery  forceps  immediately  applied  to  the  wall  of  the  sac  on 
each  side  of  the  incision;  the  fluid  having  escaped,  a  finger 
may  be  introduced  into  the  sac  and  the  testicle  examined;  if 
desired,  it  may  be  brought  out  through  the  sac,  looked  at,  and 
returned. 

In  the  older  method  of  performing  the  operation  quite  a  long 
incision  was  made,  and  a  few  sutures  were  passed  through  the 
wall  of  the  tunica,  brought  out  through  the  skin  of  the  scrotum 


Fig.  29s.— Eversion  of  tunica  vaginalis  for  the  cure  of  hydrocele. 


SO  as  to  fasten  the  wall  of  the  tunica  to  the  scrotum,  and  the  wound 
then  packed  with  gauze,  which  was  removed  in  a  few  days;  this 
left  a  fistulous  opening  which  took  some  time  to  heal,  but  was  often 
successful  in  curing  the  annoying  hydrocele.  In  the  second 
method,  which  is  a  modification  of  the  first,  many  surgeons,  after 
incising  the  sac,  remove  the  tunica  almost  entirely,  and  then, 
under  proper  antiseptic  precautions,  immediately  sew  up  the  in- 


OPERATION    FOR    HYDROCELE 


625 


cision.     This  method  has  many  followers,  and  is  at  the  present 
time  very  generally  used. 

The  third  method,  originally  devised  by  the  French,  but  erro- 
neously credited  to  the  Germans,  is  to  make  the  incision  through 
the  sac,  releasing  the  fluid ;  a  finger  is  then  inserted  into  the  wound, 


Fig.  296. — Operation    recommended  for  the  radical  cure  of  hydrocele:    i,  Opening  sac;    2, 
packing  cavity  with  gauze  ;    3,  method  of  stitching  opening. 


and  the  testicle  pulled  out,  which  has  the  effect  of  turning  the  sac 
inside  out — in  other  words,  inverting  it;  the  skin  wound  is  then 
sutured  immediately  over  the  testicle.  From  without  inward  then 
the  order  would  be :  first,  skin ;  second,  testicle ;  third,  sac ;  instead 
of — first,  skin;  second,  sac;  third,  testicle,  as  is  the  normal  order. 
This  procedure  almost  absolutely  prevents  any  recurrence  of 
40 


626  TREATMENT   OF    DISEASES    OF    THE    TESTICLE 

fluid  in  the  sac.  When,  however,  the  walls  of  the  sac  are  very 
thick,  this  procedure  cannot  be  carried  out,  for  when  the  testicle 
is  pulled  out  through  the  wound  and  the  sac  inverted,  the  mass 
is  so  large  that  there  is  not  skin  enough  in  the  scrotum  to  cover  it. 
The  waiters  were  among  the  first  to  perform  this  operation  in  this 
country;  they  also  published  one  of  the  first  articles  in  English 
describing  it. 

The  reaction  following  this  operation  is  generally  marked,  and 
the  patient  should  be  kept  in  bed  for  a  week  or  two,  at  the  end  of 
which  time  the  swelling  of  the  testicle,  which  as  a  rule  takes  place, 
subsides.  Following  any  of  these  operations  rest  in  bed  should 
be  insisted  upon  so  long  as  the  testicle  is  swollen,  and  warm  or 
cooling  applications,  if  it  seem  best,  should  be  made  to  the 
inflamed  parts.  At  times  severe  pain  in  the  abdomen  follows 
the  removal  of  fluid  from  the  sac.  In  these  cases  morphin  may 
be  given,  the  pain  generally  lasting  only  a  few  hours. 

The  ideal  operation  for  the  radicalcure  of  hydrocele  has  not 
yet  been  discovered ;  the  following  method  of  operation,  however, 
seems  to  us  to  possess  certain  advantages  deserving  of  considera- 
tion. One  of  these  is  that  it  tends  to  preserve  the  function  of  the 
testicle.  By  removing  the  tunica  the  natural  covering  of  the 
testicle  is  destroyed,  and  it  would  seem  to  follow,  as  a  matter  of 
course,  that  the  adhesion  wdth  connective  tissue  that  would  take 
place  between  the  testicle  and  the  skin,  through  its  power  of  con- 
traction, would  have  a  bad  effect  upon  the  functional  capacity  of 
the  organ.  The  same  objection  holds  good  for  the  operation  of 
inA^ersion  of  the  tunica  just  mentioned.  Excluding  these  two 
operations,  the  old-fashioned  operation  first  described  now  remains 
to  be  considered.  As  against  this  method  may  be  mentioned  the 
fact  that  it  was  not  always  successful,  often  leaving  a  sinus  that 
was  likely  to  persist  for  many  weeks. 

From  a  suggestion  of  Dr.  Ramon  Guiteras,  the  writers  were  led  to 
adopt,  in  their  hospital  and  private  practice  several  years  ago,  a 
method  for  which  they  claim  no  particular  originality,  since  it  is 
merely  a  modification  of  the  old  operation ;  it  is,  however,  generally 
successful,  and  is  comparatively  easy  to  perform.  To  obtain  the 
best  results  it  is  necessary  that  great  care  should  be  given  to  detail 
and  to  asepsis.     The  operation  may  be  performed  in  the  surgeon's 


OPERATION    OF   EPIDIDYMECTOMY  627 

office,  the  patient  being  sent  home  in  a  carriage.  The  scrotum 
having  been  rendered  aseptic,  cocain  is  injected  over  the  site  of  the 
proposed  incision;  ethyl  chlorid  is  next  sprayed  on,  and  a  small 
incision,  about  an  inch  in  length,  much  smaller  than  was  the 
custom  to  use  in  the  original  operation,  is  made  down  into  the  sac, 
and  the  fluid  allowed  to  escape.  The  walls  of  the  tunica  and  scro- 
tum are  now  carefully  stitched  together  with  many  very  fine  catgut 
sutures.  If  great  care  as  regards  cleanliness  and  sterilization  is 
not  observed  in  performing  this  operation,  and  if  the  wound 
does  not  receive  the  proper  after-care,  infection,  followed  by  slough- 
ing in  the  wound  between  the  skin  and  the  tunica,  is  likely  to  take 
place.  After  the  scrotum  and  skin  have  been  carefully  sutured,  a 
very  narrow,  ribbon-shaped  strip  of  gauze  is  introduced  into  the 
wound  and  packed  down  quite  firmly.  To  obtain  the  best  results 
it  is  necessary  to  leave  the  gauze  in  the  sac  for  at  least  four,  and 
possibly  ten,  days,  provided  there  has  been  no  rise  in  temperature, 
and  that  the  discharge  gives  off  no  offensive  odor,  or  that  no  unto- 
ward symptom  arises  rendering  its  earlier  removal  advisable.  At 
the  end  of  this  time  the  gauze  ma}^  be  removed  and  the  patient 
allowed  to  leave  his  bed  and  go  about.  Any  existing  sinus  will 
close  in  a  few  days,  instead  of  persisting  for  weeks  or  months,  as 
was  formerly  the  case  when  the  original  operation  was  performed. 
The  modifications  here  described  may  seem  unimportant,  but 
experience  has  convinced  the  writers  that  they  are  worth  while, 
for  when  the  hydrocele  is  cured  as  the  result  of  this  operation, 
the  testicle  still  retains  its  natural  covering. 

Encysted  hydroceles  of  the  cord  are  generally  small,  and  are  often 
mistaken  by  the  laity  for  a  supernumerary  testicle.  They  are 
generally  about  the  size  of  a  marble,  and  give  rise  to  no  pain  or 
suffering.  They  should  be  aspirated  with  a  fine  needle  or  fine 
trocar,  and  their  entire  contents  allowed  to  escape;  when  this  is 
done,  they  disappear  and  do  not  return. 

Epididymectomy 

This  operation  consists  in  removing  the  whole  or  a  portion  of  the 

epididymis.     An  incision  is  made  through  the  scrotum,  and  the 

epididymis  exposed;   beginning  at  the  tail  of  the  epididymis,  it 

may  be  dissected  off,  working  from  tail  to  the  head.     The  culdesac 


628  TREATMENT   OF   DISEASES   OF   THE   TESTICLE 

of  the  tunica  vaginalis  supports  the  tail  of  the  epididymis  from 
the  testicle  proper,  thus  rendering  dissection  of  the  former  easy 
unless  it  is  bound  down  by  adhesions.  The  blood-supply  is  more 
abundant  about  the  head  than  about  the  tail  of  the  epididymis. 
Instead  of  removing  the  entire  body,  only  a  portion  of  the  epididy- 
mis may  be  removed,  as  the  surgeon  sees  fit. 

After  the  epididymis,  or  a  portion  of  it,  has  been  removed, 
and  all  bleeding  points  have  been  carefully  ligated,  the  wound 
should  be  packed  lightly  with  gauze  and  allowed  to  granulate; 
or,  if  healthy,  it  may  be  completely  sewed  up,  as  much  of  the 
albuginea  as  possible  being  sewed  over  the  resected  area.  There  is 
much  diversity  of  opinion  regarding  the  value  of  this  operation. 
It  has  received  a  great  deal  of  attention  from  writers,  and  many 
favorable  results  have  been  claimed  for  it,  particularly  in  cases  of 
tuberculosis  of  the  epididymis  or  testicle.  When  the  epididymis  is 
removed,  wholly  or  in  part,  a  portion  of  the  testicle  itself  may,  if 
desired,  be  removed  simultaneously,  or  a  cheesy  nodule  in  the 
epididymis  may  be  simply  curetted  out  and  packed  with  iodoform 
gauze.  So  far  as  personal  observation  goes,  the  favorable  results 
claimed  for  epididymectomy  have  not  been  substantiated.  This 
operation  is  perhaps  indicated  in  some  cases  of  actual  or  suspected 
tuberculosis  of  the  epididymis.  It  is  very  rarely  demanded  for  any 
other  disease.  In  a  case  of  tuberculosis  the  operation  may  be  un- 
dertaken, and,  if  it  proves  unsuccessful,  the  entire  organ  may  be 
removed  later  on.  It  should  be  borne  in  mind  that  these  tubercu- 
lous infections  sometimes  progress  rapidly,  and  that  an  incomplete 
operation,  such  as  this  is,  tends  occasionally  to  hasten  the  progress 
and  disseminate  the  disease.  The  patient's  condition  should, 
therefore,  be  watched  very  carefully;  following  the  operation  he 
should  be  seen  often,  and  the  surgeon  should  be  prepared  to  per- 
form castration  at  a  moment's  notice. 

Castration 
Castration,  or  the  removal  of  the  testicle,  is  generally  required 
either  for  tumor  of  the  testicle,  generally  of  a  malignant  type, 
or,  most  often,  for  tuberculosis;  occasionally  injury  necessitates 
its  removal.  Castration  was  formerly  practised  for  the  relief  of 
enlarged  prostate,  but  at  present  this  procedure  has  been  aban- 
doned in  the  treatment  of  that  condition.     In  view  of  the  fact 


OPERATION    OF    CASTRATION 


629 


that  the  operation  is  consented  to  only  as  a  last  resort,  and  that 
any  right-minded  surgeon  would  hesitate  to  practise  it  unless  the 
necessities  of  the  case  urgently  demanded  it,  castration  is  not  often 
performed  unnecessarily. 

Ordinarily,  castration  is  a  very  simple  operation.  An  incision 
about  two  or  three  inches  long,  extending  from  the  upper  border 
of  the  scrotum  up  into  the  groin,  is  made  through  the  skin  and 


Fig.  2g7. — A,  Operation  of  castration.    B,  Method  of  tying  stump  of  the  cord. 


fascia  down  to  the  cord;  the  cord  is  isolated,  and  with  the  tes- 
ticle attached,  is  pulled  out  through  the  opening;  ligatures  are 
then  placed  about  it,  and  with  a  knife  or  scissors  the  cord  is 
severed  below  the  ligature  and  the  testicle  thus  removed.  The 
edges  of  the  wound  in  the  scrotum  are  brought  together,  and  a 
small  gauze  drain  is  inserted  at  its  lower  angle  and  allowed  to 
remain  for  a  few  days.  Ordinarily,  the  writers  advocate  an  inci- 
sion longer  than  laid  down  in  text-books  on  surgery,  extending  to- 
ward the  bottom  of  the  scrotum,  and  longer  than  shown  in  the 
illustration,  for  the  purpose  of  securing  better  drainage.    It  is  gen- 


630  TREATMENT    OF    DISEASES    OF    THE    TESTICLE 

erallv  considered  good  surgery,  in  removing  the  testicle,  to  perform 
the  amputation  as  high  up  on  the  cord  as  practicable.  .Some  writers 
also  recommend  separating  the  vas  deferens  from  the  cord,  pulling 
on  it  gentlv,  and  dissecting  it  away  wherever  possible;  in  other 
words,  attempting  to  "unravel"  it,  so  to  speak,  so  that  in  some 
cases  it  will  be  possible  to  amputate  it  an  inch  or  two  higher  than 
is  the  cord.  This  is  done  in  the  belief  that  the  more  of  the  vas 
deferens  removed  in  tuberculosis  of  the  testicle,  the  less  tendency 
is  there  for  the  seminal  vesicles  to  become  infected.  In  a  case 
occurring  in  the  writers'  hospital  service,  in  which  this  modifica- 
tion of  the  operation  was  very  successfully  performed,  an  in- 
tensely painful  rectal  neuralgia  followed;  this  tended  to  discour- 
age us  with  the  procedure.  Although  in  other  cases  the  vas  was 
unraveled  and  amputated  as  high  as  possible  without  any  bad  after- 
results,  the  writers  do  not  believe  that  they  have  accomplished 
any  particular  good  by  so  doing,  and  consider  it  a  procedure  of 
little  value,  and  believe  it  better  to  divide  the  cord  without  un- 
raveling the  vas.  In  dividing  the  cord  below  the  ligature,  the 
ligature  is  allowed  to  remain;  in  some  cases  the  portion  below 
sloughs  off  and  considerable  swelling  takes  place  in  the  extreme  end 
of  the  stump  of  the  cord.  To  obviate  this  the  writers  place  a  tem- 
porarv  ligature  about  the  cord  before  amputating,  and  then  sever 
the  cord;  the  ligature  is  then  loosened  slightly  and,  with  very 
small  artery  forceps,  the  bleeding  points  that  appear  in  the  stump 
are  picked  up  carefully  and  ligated  with  fine  catgut,  after  which  the 
ligature  is  removed  entirely.  Following  the  amputation  and  re- 
moval of  the  testicle  it  is  generally  wise  to  leave  a  small  drain  at 
the  bottom  of  the  wound  for  a  few  days.  Considerable  local  re- 
action around  the  stump  of  the  cord  immediately  follows  the  oper- 
ation, and  marked  swelling,  that  seems  inclined  to  extend  up  the 
abdomen,  may  occur.  If  proper  attention  is  paid  to  drainage  and 
an  ice-bag  applied,  this  will  generally  diminish.  In  some  cases 
changing  the  position  of  the  patient,  so  as  to  secure  better  drainage, 
is  in  itself  enough  to  cause  an  increasing  and  angry-looking  swelling 
to  disappear  entirely.  In  removing  a  testicle  that  has  become 
very  much  enlarged,  particularly  as  the  result  of  malignant  dis- 
ease, the  infiltration  around  the  testicle  is  so  extensive  that  it  ap- 
pears as  if  it  were  in  a  mold.  In  such  cases  it  must  be  dissected  out 
with  considerable  care.     After  its  removal  the  thickened  mass 


OPERATIOX    FOR    RETAINED   TESTICLE  63 1 

may  be  dug  out  from  the  scrotal  walls,  care  being  taken  not  to  in- 
jure the  dividing  wall  between  the  two  testicles. 

Treatment  for  Inguinal  Retention  of  the  Testicle 
In  the  writers'  personal  experience  these  cases  occur  with  com- 
parative frequency.  They  are  of  congenital  origin,  the  testicle 
rarely  giving  trouble  when  retained  in  the  abdomen.  They  seldom 
give  rise  to  pain;  when  they  do,  however,  operation  should  be 
performed.  The  condition  manifests  itself  as  a  mass  in  the  groin, 
resembling  hernia,  for  which  it  is  sometimes  mistaken.  Two 
forms  of  operation  are  employed  for  the  relief  of  these  cases: 
one  consists  in  removing  the  mass,  and  the  other  aims  to  restore 
the  organ  to  the  scrotum  and  anchor  it  there.  The  operation  of 
removal  should  be  carried  out  in  the  same  manner  as  the  ordinary 
operation  of  castration,  the  incision  being  made  in  the  groin  over 
the  misplaced  organ.  It  is  a  very  difficult  matter  to  anchor  a 
misplaced  testicle  permanently  in  the  scrotum,  and  where  it  is  so 
anchored,  it  is  doubtful  if  it  will  ever  possess  any  functional  ac- 
tivitv.  The  good  results  from  various  operations  that  have  so 
often  been  reported  have  not  been  attained  in  the  writers'  practice, 
and  they  are  generally  inclined,  therefore,  particularly  when  the 
case  to  be  operated  upon  is  an  adult,  to  recommend  removal  of 
the  organ.  The  difficulty  in  all  operations  for  effecting  retention 
of  a  misplaced  organ  in  the  scrotum  is  that  the  cord  has  become  so 
shortened  that  when  the  testicle  is  brought  down  into  the  scrotum 
and  anchored  there,  the  tension  of  the  cord  will  soon  cause  it  to 
ascend  again  into  the  groin.  Another  difficulty  is  that  of  obtain- 
ing a  sufficiently  long  cord  to  allow  of  the  organ  being  brought  well 
down  into  the  base  of  the  scrotum.  The  following  method  of 
operating  on  this  class  of  cases  is  the  one  that  will  probably  give 
the  best  results.  It  is  the  operation  devised  by  Dr.  Arthur  D. 
Bevan,  of  Chicago.  The  testicle  is  exposed  in  the  inguinal  region. 
The  vaginal  process  of  peritoneum  is  divided  and  ligated  above  it 
as  a  hernial  sac;  the  portion  of  peritoneum  that  surrounds  it  is 
closed  b}^  a  purse-string  suture.  The  cord  is  lengthened  by  pulling 
upon  it  and  dissected  free  from  connective  tissue ;  a  place  is  made 
for  the  testicle  in  the  scrotum  and  it  is,  with  its  artificial  tunica 
vagina,  brought  down  into  it  and  kept  there  by  a  purse-string 
suture  run  through  the  neck  of  the  scrotum.     If  sufficient  length 


632  TREATMENT   OF    DISEASES  OF  THE   TESTICLE 

of  cord  cannot  be  obtained,  the  spermatic  blood-vessels  may  be 
ligated,  trusting  to  the  artery  of  the  vasa  deferentia  to  nourish  the 
testicle. 

There  are  several  other  methods  of  treatment  for  this  condition. 
Dr.  Paul  Coudray'  claims  that  where  hernia  is  not  associated 
with  the  ectopia  that  massage  and  traction,  together  with  the  use 
'of  a  properly  applied  bandage,  will  in  time  cause  the  organ  to 
remain  in  the  scrotum,  while  with  hernia  it  is  necessary  to  do  a 
radical  operation.  Another  method  that  has  frequently  been 
advocated  is  to  pull  the  testicle  through  a  slit  in  the  bottom  of 
the  scrotum  and  allow  it  to  remain  in  that  position  for  a  time, 
the  contraction  of  the  scrotal  wall  preventing  it  from  slipping 
upward   into   the    groin. 

C.  B.  Keetly-  brings  the  testicle  through  the  bottom  of  the 
scrotum,  then  makes  an  incision  in  the  corresponding  portion  of 
the  thigh  of  the  same  extent  as  the  incision  in  the  bottom  of  the 
scrotum,  attaches  the  testicle  to  the  cellular  tissue  underneath 
the  skin,  and  sews  together  the  opening  in  the  skin  and  the  scrotum. 
He  reports  a  considerable  number  of  cases  operated  on  in  this  man- 
ner. In  detail  his  procedure  is  as  follows:  "  The  testicle  and  cord 
having  been  thoroughly  freed  from  everything  but  the  musculo- 
fibrous  bands  form  in  the  gubernaculum,  which  are  generally 
attached  to  the  pillars  of  the  external  ring,  especially  the  internal 
pillar,  the  "gubernaculum  is  divided,  as  far  away  as  possible  from 
the  testicle.  A  pair  of  forceps  is  then  passed  from  below  upward, 
through  the  hole  in  the  scrotum,  and  the  gubernaculum  is  seized 
by  it  and  pulled  right  through  the  scrotum  until  it  can  be  seen 
through  the  hole  in  the  skin  of  the  scrotum.  At  the  same  time  the 
tunica  vaginalis  testis  should  also  be  pulled  down  into  the  scrotum, 
although  it  is  not  absolutely  necessary  to  keep  the  testis  in  its 
serous  bag.  Indeed,  I  have  often  omitted  to  attend  to  this  point. 
The  posterior  borders  of  the  aperture  of  the  skin  of  the  scrotum 
and  thigh  are  next  united  by  continuous  silkworm-gut  suture 
left  long  at  both  ends.  Now  the  gubernaculum  testis  is  sutured 
with  strong  catgut  to  the  fascia  lata  of  the  thigh,  and  lastly  the 
original  silkworm-gut  suture  is  used  to  complete  the  union  of  the 

^  "  Traitment  de  I'ectopie  Testicularie,  oar  Male,"  "  La  Progres  Medical," 
January,  1907. 

-  "  Lancet,"  1895. 


OPERATION   FOR   RETAINED   TESTICLE 


633 


skin  apertures  in  the  scrotum  and  thigh  to  one  another.  The 
hernia  which  is  generally  present  is  operated  on  for  radical  cure 
in  the  way  the  surgeon  thinks  best  for  the  individual  case." 

This  method  was  first  demonstrated  in  1894.  The  authors 
recommend  to  leave  the  testis  attached  to  the  thigh  for  five 
months.  Fritz  de  Beule^  recommends  the  same  procedure,  having 
devised  the  operation  before  becoming  acquainted  with  the  work 


Fig.  298.— Method  of  retaining  testicle  in  thigh  (redrawn  from  Keetly). 

of  C.  B.  Keetly.  His  procedure  is  about  the  same,  with  the  excep- 
tion that  he  releases  the  testicle  retained  in  the  thigh  at  the  end 
of  about  five  weeks.  Gersuny  and  Witzel  developed  a  method  of 
opening  the  wall  which  divides  the  scrotum  into  two  halves,  and 
places  the  right  testicle  in  the  left  cavity  and  the  left  testicle  in 
the  right.     Very  recently  Dr.  Simard-  has  reported  a  case  oper- 

^  "Anal.  Soc.  Belg.  de  Chir.,"  1906. 
^  "Bull.  Med.  de  Quebec,"  1907. 


634  TREATMENT    OF    DISEASES    OF    THE    TESTICLE 

ated  on  in  this  manner  in  which,  after  the  end  of  six  months, 
the  results  were  found  to  be  good.  We  have  seen  one  case  which 
had  been  operated  upon  by  the  Keetly  method  in  which  apparently 
good  results  had  been  achieved,  and  are  incHned  to  believe,  judging 
from  the  histories  of  reported  cases,  that  in  a  proportion  of  cases 
this  method  will  be  found  efficacious.  It  is  claimed  by  the  author 
that,  through  operating  in  this  manner,  the  life  of  the  testicle  is 
not  destroyed. 

The  Treatment  of  Atrophy  of  the  Testicle 
For  the  local  treatment  of  atrophy  of  the  testicle  some  form  of 
electricitv  has  for  many  years  been  advocated.  The  interrupted 
or  continuous  current  or  static  electricity  is  employed.  When 
the  first-named  currents  are  used,  one  of  the  electrodes  is  applied 
over  the  lower  portion  of  the  spine  and  the  other  along  the  peri- 
neal and  scrotal  tissues.  Such  measures  should,  however,  be 
adopted  tentatively,  and  the  strength  and  duration  of  the  applica- 
tion modified  to  meet  the  demands  of  the  individual  case. 

The  Treatment  of  Injuries  to  the  Testicle 
The  treatment  of  injuries  of  the  testicle  is  largely  dependent  upon 
their  severity.  Patients  should  be  put  to  bed  and  the  scrotum 
supported  in  a  manner  similar  to  that  recommended  for  the  treat- 
ment of  other  acute  inflammatory  conditions.  Either  hot  or  cold 
applications,  according  to  which  affords  the  most  relief,  should  be 
used.  The  ice-bag  is  ordinarily  the  best  external  application,  but, 
as  previously  mentioned,  it  must  be  remembered  that  sloughing 
is  likely  to  follow  its  too  prolonged  use. 

After  a  severe  injury,  such  as  a  violent  kick,  considerable  swell- 
ing is  likeh^  to  occur,  and  an  effusion  of  blood  that  gives  rise  to  a 
hard  tumor,  known  as  a  hematocele,  may  occur.  These  hemato- 
celes may  persist  for  weeks  or  months.  If  they  are  not  eventually 
absorbed,  they  should  be  removed.  Penetrating  wounds,  either 
immediately  or  shortly  after  they  have  been  received,  sometimes 
permit  the  testicle  to  prolapse  through  the  scrotum,  and  occasional 
hernia  of  the  testicle  results.  In  these  cases,  either  with  or 
without  hernia,  the  organ  should  be  replaced  and  the  wound 
sutured  under  proper  antiseptic  precautions.  Whenever  practic- 
able, the  testicle  should  be  replaced  as  soon  as  possible  after  the 


OPERATION  FOR  VARICOCELE  635 

injury,  before  adhesions  between  it  and  the  surrounding  tissue  have 
had  an  opportunity  to  form. 

The  Treatment  of  Varicocel-E 
There  is  probably  no  other  condition  that  has  offered  a  more 
lucrative  field  for  the  practice  of  charlatanry  than  varicocele. 
This  condition,  which  consists  of  an  enlargement  of  the  veins 
of  the  spermatic  cord,  very  rarely  gives  rise  to  any  physical  symp- 
toms or  effects  any  damage  if  allowed  to  go  untreated;  the  feeling 
of  weight,  uneasiness,  burning,  and  the  like  in  the  scrotum,  or 
pain  in  the  back,  often  thought  to  be  caused  by  it,  being,  we 
think,  due  to  neurasthenia,  or  possibly  reflex  from  some  inflam- 
matory condition  in  the  urethral  tract.  Very  often,  however,  it 
produces  mental  distress.  The  application  of  a  suspensory  ban- 
dage is,  in  most  cases,  all  that  is  required.  When  surgical  pro- 
cedure is  demanded,  one  of  three  types  of  operation  may  be 
chosen. 

The  first,  subcutaneous  ligation,  has,  to  a  great  extent,  become 
obsolete.  It  is,  nevertheless,  recommended  by  many,  and  various 
methods  of  performing  it  have  been  described  in  the  older  text- 
books on  surgery,  to  which  reference  is  made.  We  do  not  com- 
mend it. 

The  second  type  of  operation  aims  to  reduce  the  redundancy 
of  the  scrotum,  by  effecting  ablation  of  part  of  the  sac.  This 
procedure  is  probably  as  useful  as  any,  as,  owing  to  the  cicatricial 
tissue  contraction  following  the  operation,  it  makes  a  natural 
suspensory  bandage  of  the  scrotum  itself.  It  is  performed  as 
follows:  The  testicles  are  pushed  up  toward  the  inguinal  gland, 
and  the  base  of  the  scrotum  is  pulled  down  and  seized  between 
the  first  and  second  fingers  of  the  left  hand,  which  are  pushed  up 
against  the  testicles  in  a  manner  similar  to  that  of  a  barber  when 
cutting  the  hair  of  the  head.  A  properly  fitting  clamp  is  then 
applied.  Any  one  of  the  appliances  that  have  been  specially 
devised  for  the  purpose,  or  any  large  clamp  with  a  curve,  or  two 
clamps  from  side  to  side,  meeting  end  to  end,  may  be  employed. 
Just  above  them,  between  the  clamps  and  the  testicle,  a  few 
U-shaped  sutures  should  be  placed,  the  fold  of  scrotum  below 
the  clamp  cut  through,  and  the  portion  of  scrotum  below  the 


636  TREATMENT   OF   DISEASES  OF   THE   TESTICLE 

clamp  removed.  The  clamps  are  then  removed,  any  bleeding 
points  ligated,  and,  if  necessary,  a  few  more  sutures  taken. 
The  patient  is  put  to  bed  and  kept  there,  and  a  dry  dressing  is 
applied  until  the  wound  has  healed. 

The  third  method  of  operating  consists  in  making  an  incision 
down  on  to  and  separating  the  cord,  in  much  the  same  manner 
as  if  the  testicle  were  to  be  removed  by  castration,  except  that 
the  incision  should  be  somewhat  lower.  After  the  cord  has  been 
isolated  well  down  to  the  epididymis  and  the  mass  of  veins  that  go 
to  make  up  the  varicocele  has  been  recognized,  the  cord  should  be 
examined  very  carefully  between  the  thumb  and  forefinger.  The 
vas  deferens,  in  the  midst  of  the  cord,  will  be  recognized  as  a  very 
small  cord  by  itself,  which  feels  like  a  piece  of  wire ;  the  sensation 
it  imparts  to  the  touch  is  so  distinctive  that  once  felt,  it  will 
afterward  be  easily  recognizable.  Great  care  must  be  exercised 
lest  the  vas  deferens  be  incised ;  it  should  be  separated  from  the 
remainder  of  the  cord,  and  the  portion  of  the  cord  containing  the 
most  distended  veins  should  be  tied  across  with  two  Hgatures,  one 
being  placed  well  down  toward  the  epididymis  and  the  other  about 
an  inch  above.  The  intervening  inch  of  the  cord,  containing  many 
of  the  enlarged  veins,  should  be  removed  by  an  incision  across  the 
cord  immediately  above  the  lower  and  just  below  the  upper  liga- 
ture, and  the  excised  piece  removed;  then  the  two  amputated 
ends  of  the  cord  should  be  brought  together,  and  the  ligatures 
that  run  across  the  cord  having  been  left  long,  should  be  tied  to- 
gether, thus  bringing  the  two  separate  ends  of  the  cord  into  approx- 
imation. In  other  words,  the  cord  is  an  inch  shorter  than  it  was 
before  the  operation;  the  vas  deferens,  however,  which  has  not 
been  interfered  with,  is  the  same  length  as  it  originally  was. 
The  ligatures  having  been  tied,  the  skin  incision  is  then  sutured. 
It  is  unnecessary  to  employ  drainage,  but  the  patient  should  be 
put  to  bed  and  should  be  kept  there  for  a  few  days,  or  until  the 
swelhng  that  takes  place  at  the  point  where  the  two  ends  of  the 
cord  are  brought  together,  and  that  makes  a  bunch  of  considerable 
size,  has  reached  its  height,  otherwise  an  annoying  orchi-epididy- 
mitis  occasionally  follows.  If  desired,  the  surgeon  may  employ  a 
combination  of  methods:  quite  a  large  portion  of  the  skin  at  the 
side  of  the  scrotum  may  be  removed,  or  the  two  operations  of 


OPERATION   FOR   TUMORS   OF   THE   TESTICLE  637 

ablation  of  the  lower  portion  of  the  scrotum  and  excision  of  the 
veins,  as  just  described,  may  be  performed. 

The  Treatment  of  Tumors  of  the  Testicle 
In  all  cases  of  tumors  of  the  testicle  where  malignancy  is  strongly 
suspected  the  writers  advocate  early  and  radical  operative  meas- 
ures. All  doubtful  cases  should  first  be  submitted  to  thorough 
antisyphilitic  treatment,  followed  by  operation  if  this  proves 
unsuccessful.  As  a  rule,  the  clinical  and  gross  anatomic  aspects 
of  the  tumor  are  sufficient  to  establish  the  diagnosis,  the  extent 
and  nature  of  the  operation  being  then  determined  at  the  operating 
table.  For  instance,  a  sessile  tumor,  as  well  as  some  teratomata, 
may  be  removed  and  the  testicle  allowed  to  remain  if  attached 
to  it  only  by  a  small  pedicle,  in  this  way  perhaps  preserving  the 
integrity  of  the  testicle.  Whenever  possible,  a  rapid  histologic 
examination,  by  means  of  frozen  sections,  should  be  made  during 
the  operation.  The  writers  have  known  the  most  serious  results  to 
follow  delay;  it  cannot,  therefore,  be  impressed  too  strongly  on 
practitioners  that,  in  the  early  stages  of  tumors  of  the  testicle,  a 
fairly  good  prognosis  as  to  recurrence  may  be  given  if  early  opera- 
tion is  permitted,  whereas  delay  is  almost  invariably  followed  by 
such  wide  dissemination  as  to  render  treatment  of  little  or  no  avail. 
The  rr-ray,  radium,  or  the  Coley  toxins  should  be  used  only  in 
inoperable  cases  or  when  operation  is  refused. 

Irrigation  and  Drainage  of  the  Seminal  Duct  and 
^  Vesicle  Through  the  Vas  Deferens 
Recently^  Dr.  William  T.  Belfield  reports  on  the  practicability 
of  using  the  vasa  deferentia  as  a  canal  from  which  drainage  of  the 
seminal  duct  may  take  place,  or  through  which  the  seminal  ves- 
icles may  be  reached  by  injected  fluid.  His  procedure  is  as  follows : 
Through  a  half -inch  incision,  under  local  anesthesia,  the  vas  is  ex- 
posed. A  transverse  or  longitudinal  incision  into  the  vas  opens  the 
canal,  and  the  blunted  needle  of  a  hypodermatic  syringe  may  be 
passed  into  the  minute  canal  and  a  watery  solution  of  any  desired 
agent  injected ;  this  liquid  traverses  the  vas  and  the  ampulla  and 

^Abstract  from  "Proceedings  of   the  American  Association  of   Genito- 
urinary Surgeons,"  June,  1906. 


638 


TREATMENT   OE   DISEASES   OF  THE   TESTICLE 


distends  the  seminal  vesicle.     This  writer  states  that  30  minims  is 
the  amount  of  fluid  that  can  safely  be  used  without  causing  sper- 


Fig.  299. — Illustrating  method  of  operating  for  relief  of  elephantiasis  of  scrotum. 


Fig.  300. — Illustrating  method  of  operating  for  the  relief  of  elephantiasis  of  scrotum. 

matic  colic  and  retention  of  urine.     If  desired,  the  vas  may  be 
kept  open  by  passing  a   fine  silkworm-gut  suture  through  the 


OPERATION    FOR    ELEPHANTIASIS  639 

lumen  of  each  cut  end.     He  states  that  by  means  of  this  method 
he  has  successfully  treated  perivesiculitis  and  allied  conditions. 

Treatment  of  Elephantiasis 
The  illustrations  given  clearly  define  the  surgical  procedure 
necessary  for  the  relief  of  this  condition,  two  semilunar  incisions 
meeting  one  another  at  the  penoscrotal  angle  and  at  the  raphe  of 
the  perineum  near  the  anus.  The  testicles  should  be  located, 
pulled  forward,  and  any  attachments  between  them  and  the  back 
of  the  scrotum  severed.  Then  the  mass  is  removed  and  the  opera- 
tive field  covered  by  bringing  the  tissues  together  by  the  line  of 
incision  shown.  It  is  recommended  by  Berger  and  Hartmann 
that  the  patient  rest  in  bed  for  two  days  preceding  the  operation, 
with  the  scrotal  contents  elevated;  through  this  procedure  the 
mass  will  be  softened  and  the  testicles  be  more  easily  located 
in  the  growth. 


CHAPTER  XXX 

SEXUAL  NEUROSES 

Neuroses  of  the  genito-urinary  system  are  of  such  frequent 
occurrence  as  to  demand  brief  consideration  here.  Patients  are 
constantly  applying  to  the  general  practitioner  for  the  relief  of 
symptoms  that  must  be  classed  as  neuroses  or  functional  dis- 
turbances of  the  sexual  organs.  The  classification  of  these  symp- 
toms is  very  difficult,  and  their  treatment  is  still  more  so.  Only 
the  more  important  divisions  will  be  considered  here ;  for  a  more 
complete  description  the  reader  is  referred  to  the  work  of  K- 
Finger,  "Der  Storungen  der  Geschlechtsfunctionen  des  Mannes," 
in  the  "Handbuch  der  Urologie,"  edited  by  Dr.  Anton  v.  Frisch 
and  Dr.  Otto  Zuckerkandl,  Wien,  1906.  There  is  also  quite  an 
exhaustive  article  on  the  subject  in  Casper's  "Urologie."  Refer- 
ence may  also  be  made  to  any  of  the  most  recent  works  on  mental 
and  nervous  diseases. 

Under  the  heading  of  neuroses  of  the  sexual  organs  it  has  been 
customary  to  consider  disturbances  in  the  function,  including 
such  conditions  as,  first,  pollutions,  under  which  heading  should 
be  grouped  such  disorders  as  spermatorrhea,  prostatorrhea,  and 
urorrhea.  These  unnatural  emissions  are  particularly  marked 
during  defecation,  or  are  abnormal  in  character  or  frequency. 
Second,  impotence,  which  is  the  complete  or  partial  inability  to 
perform  the  sexual  act.  More  or  less  connected  with  it  are  the 
various  types  of  sexual  weakness  when  not  due  to  the  natural  con- 
ditions of  youth  or  old  age.  Third,  sterility,  which  is  the  term 
used  to  express  the  inability  to  impregnate  healthy  females.  This 
last  condition  has  been  classified  into  divisions  made  up  of  indi- 
viduals who  are  sterile  through  impotency  and  those  whose  semen 
is  unfertile. 

The  writers  take  the  same  stand  as  does  Finger,  in  his  article 
previous!}^  referred  to,  that  such  conditions  as  spermatorrhea  and 
prostatorrhea  are  but  symptoms  pointing  to  some  diseased  state. 

640 


SEXUAL    NEUROSES  64 1 

For  example,  the  discharge  of  semen,  if  it  should  occur  during 
defecation  or  during  micturition,  may  be  an  evidence  of  paralysis 
of  the  ejaculatory  duct,  which  in  turn  may  be  due  to  peripheral 
nerve  disturbance  following  a  catarrhal  inflammation  at  the  neck 
of  the  bladder,  or  to  some  organic  disease  of  the  spinal  cord.  Clini- 
cally, the  discharge  that  occurs  under  these  conditions  is  more 
likely  to  be  either  a  urorrhea,  in  which  no  other  elements  are  found 
microscopically  than  those  normal  to  the  urethra,  or,  what  is  still 
more  common,  a  prostatorrhea,  in  which  the  discharge  microscopic- 
ally gives  evidence  of  coming  from  the  prostatic  gland.  If  leuko- 
cytes are  found  in  abnormal  proportion  in  any  of  these  discharges, 
this  would  be  indicative  of  inflammation  existing  in  the  urethra, 
prostate,  or  seminal  vesicles,  and  could  be  anatomically  consid- 
ered as  chronic  urethritis  or  seminal  vesiculitis.  Microscopic  ex- 
aminations of  the  urethral  discharge  would,  of  course,  help  mate- 
rially to  differentiate  the  conditions. 

For  convenience  of  description,  we  divide  this  subject  into 
three  general  classes:  (i)  Those  in  which  there  is  some  organic 
disease  of  the  urinary  or  sexual  apparatus.  (2)  Those  in  which 
the  condition  is  due  to  a  general  disease  or  habit,  to  a  mental  de- 
fect, or  to  a  lesion  of  the  nervous  system.  (3)  Those  cases  in 
which  there  is  a  combination  of  the  general  disease  or  mental  dis- 
order, with  actual  lesions  or  pathologic  disturbances  in  the  genito- 
urinary tract.  This  last  class  would,  therefore,  be  a  mixed  one, 
made  up  of  members  of  the  other  two  classes  in  some  of  whom  the 
organic  disturbances,  and  in  others  the  psychic  phenomena,  would 
predominate. 

Class  I. — In  considering  the  first  class, — those  patients  in 
whom  there  exists  some  essential  organic  lesion  in  the  genito- 
urinary tract, — we  find  that  chronic  posterior  urethritis  and  pros- 
tatitis, onanism,  coitus  reservans,  and  too  frequent  sexual  inter- 
course may  be  considered  as  the  four  principal  causative  factors. 
Examination  of  these  cases  gives  evidence  that  chronic  catarrhal 
and  inflammatory  conditions  of  the  prostate  and  of  the  seminal 
vesicles  are  often  due  to  these  causes.  It  is  believed  by  some  that, 
clinically,  these  conditions  of  the  prostate  and  seminal  vesicles 
present  different  pictures,  varying  according  to  their  respective 
causes. 
41 


642  SEXUAL    NEUROSES 

The  clinical  symptoms — and  this  refers  to  a  chronic  and  not  to 
an  acute  inflammatory  state — are  a  burning  sensation  during,  and 
an  increased  desire  for,  micturition  and  a  sensation  of  burning 
and  pressure  in  the  bladder  and  perineum.  Endoscopic  examina- 
tion shows  that  the  colliculus  seminalis  may  be  much  enlarged,  and 
the  pars  prostatica  chronically  inflamed.  In  addition,  an  excitable 
sexual  weakness  may  be  present.  Finger  believes  that  the  excit- 
able weakness  from  sexual  excess  and  that  from  coitus  reservans 
resemble  each  other  closely,  whereas  excitable  weakness  due  to 
onanism  resembles  that  due  to  chronic  urethritis,  except  that  it  is 
somewhat  slower  in  presenting  itself.  Clinically,  the  symptoms 
due  to  coitus  reservans,  occurring  as  they  generally  do  in  men  of 
middle  age  or  over,  resemble  very  much  the  earlier  symptoms  of 
prostatic  hypertrophy.  In  fact,  any  one  of  the  four  causes  men- 
tioned may,  in  time,  become  the  exciting  factor  of  prostatic  hyper- 
trophy, owing  to  the  formation  of  cicatricial  tissue,  the  result  of 
the  chronic  inflammation  closing  up  the  mouths  of  the  prostatic 
acini;  or  it  may  be  the  cause  of  prostatic  atrophy,  owing  to  the 
formation  of  cicatricial  tissue  between  the  acini,  which  compresses 
them,  and  is  followed  by  parenchymatous  atrophy.  A  reference  to 
the  pathology  of  this  condition  will  be  found  under  the  head  of 
Diseases  of  the  Prostate. 

Among  the  abundant  proofs  that  the  inflamed  conditions  men- 
tioned are  traceable  to  the  four  causes  given  are  the  evidences 
of  chronic  inflammation  existing  at  the  neck  of  the  bladder;  these 
evidences  consist  of  the  presence  of  shreds,  lecithin  bodies,  and  ex- 
cessive numbers  of  leukocytes  in  the  urine;  and,  as  revealed  by 
the  endoscope,  a  chronic  inflammatory  condition  with  enlarge- 
ment of  the  colliculus  in  the  pars  prostatica.  It  seems  reasonable 
to  assume  that,  as  this  chronic  inflammatory  condition  takes  place, 
it  causes  a  similar  condition  of  the  nerve-endings  in  that  portion 
of  the  body;  and,  that  this  interferes  with  the  proper  conductiv- 
ity between  the  nerves  and  the  spinal  cord  and  brain,  giving  rise 
to  a  complication  that  may  be  termed  a  sexual  neurasthenia.  The 
inflammatory  conditions,  their  causes,  relation,  and  the  symptoms 
they  give  rise  to  are  well  demonstrated. 

Further,  in  addition  to  the  symptoms  previously  cited,  there 
are  present  the  manifestations  of  general  neurasthenia.     Follow- 


SKXUAL    NEUROSES  643 

ing  the  stage  marked  by  frequent  pollutions  and  early  ejaculations, 
a  second  stage  generally  succeeds,  according  to  Casper,  charac- 
terized by  neuralgia  of  the  lumbosacral  plexus  and  impaired 
potency;  this  is  followed  by  a  third  stage,  in  which  the  neu- 
rasthenia may  extend  up  the  spinal  cord,  causing  a  cerebro- 
spinal neurasthenia.  With  this  multiplicity  of  symptoms  there 
are  associated  derangements  of  the  circulatory  and  digestive 
apparatus. 

The  differential  diagnosis  between  sexual  neurasthenia  and 
neurasthenia  due  to  some  other  cause,  but  in  which  there  may  be 
disturbances  of  the  sexual  function  as  a  symptom,  is,  however, 
extremely  difficult.  These  cases  of  general  neurasthenia,  which 
are  more  often  due  to  heredity,  worry,  or  malaria  than  to  any 
other  factors,  may  be  differentiated  from  sexual  neurasthenia  in  the 
following  manner : 

In  general  neurasthenia  there  is  no  disease  of  the  pars  prostatica 
or  but  so  slight  an  organic  disturbance  that  it  is  not  in  itself  suf- 
ficient to  give  rise  to  the  condition.  In  these  patients,  as  would 
be  expected,  the  disease-picture  is  a  changing  one.  If  they  are 
impotent  or  semi-impotent,  there  are  times  when  normal  potency 
alternates  with  excitable  weakness,  and  these  symptoms  follow 
one  another  at  short  intervals.  Sexual  symptoms  in  these  cases 
run  parallel  with  the  other  symptom.s  of  neurasthenia,  or  a  cer- 
tain alternation  of  symptoms  is  noticeable — as,  for  instance, 
those  of  sexual  neurasthenia  predominating  one  day,  gastric 
svmptoms  another,  and  the  symptoms  of  cerebrospinal  neuras- 
thenia another.  In  sexual  neurasthenia,  on  the  other  hand, 
sexual  symptoms  are  constantly  evident,  perhaps  combined 
in  greater  or  less  degree  with  the  general  neurasthenic  manifes- 
tations. 

The  writers  have  endeavored  to  describe  briefly  the  symptoms 
and  the  pathology,  so  far  as  they  are  known  up  to  the  present 
time,  of  what  may  properly  be  termed  sexual  neurasthenia,  which, 
as  the  reader  will  easily  perceive,  also  embraces  certain  forms 
of  impotence,  spermatorrhea,  and  similar  conditions. 

Space  does  not  permit  a  consideration  of  all  the  conditions  that 
could  properly  come  under  the  first  division.  Impotence  due  to 
trauma,  malformations  of  the  genital  apparatus,  ulceration,  gan- 


644 


SEXUAL   NEUROSES 


grene,  neoplasm,  small  frenum,  warts,  and  elephantiasis  could  all 
be  considered  in  this  class.  It  may  be  due  to  shrinking  of  the 
corpora  cavernosa,  in  whole  or  in  part, 
which  may  occur  as  the  result  of  age. 
Hydrocele,  epididymitis,  and  orchitis  all 
belong  here.  Sterility  may  also  be  due 
to  some  of  the  above  causes. 

The  prognosis  for  the  cure  of  the  pa- 
tients in  this  class  is  that  for  the  cure  of 
the  inflammatory  conditions,  the  neuras- 
thenia, and  the  impotence,  and  is  good  in 
those  cases  in  which  the  original  cause  can 
be  made  out  and  eradicated. 

Treatment. — The  exciting  cause  should 
be  removed,  the  general  health  improved, 
and  proper  local  treatment  instituted  for 
the  chronic  inflamed  condition  at  the 
neck  of  the  bladder  if  this  be  present. 
If  removing  the  cause  and  building  up  the 
general  health  are  not  sufficient,  mental 
therapeutics  may  do  good.  Some  benefit 
may  accrue  from  giving  the  patient  a  clear 
description  of  his  condition.  Tonics  of 
iron,  manganese,  and  phosphorus  are  to 
be  prescribed.  Sea-bathing,  exercise  in 
the  open  air,  and  some  occupation  that  will 
divert  the  patient's  mind  from  the  local 
disturbance  should  be  recommended. 

The  local  treatment  should  be  carried 
out  with  the  utmost  gentleness,  as  these 
neurasthenic  patients  are  very  easily  irri- 
tated and  react  badly  to  any  treatment 
that  is  at  all  heroic.  The  passing  of  a  silk 
bougie,  followed  later  by  the  Kollmann 
dilator,  irrigations  or  instillations  of 
weak  solutions  of  silver  nitrate,  and  pros- 
tatic massage  may  all  be  employed  tentatively  and  their  effect 
observed.     The  application  of  an  ointment,  for  example,  one  con- 


Fig.  301. —  Meschung  sound  for 
application  of  cold. 


SEXUAL    NEUROSES  645 

taining  i  per  cent,  of  aristol,  on  a  grooved  sound  or  on  a  Young's 
ointment  applicator  will  prove  of  benefit.  By  introducing  a 
straight  endoscope  and  touching  the  colliculus  once  a  week  with  a 
silver  nitrate  solution  (10  per  cent.)  appHed  by  means  of  a  cotton- 
wound  applicator,  good  may  be  accomplished.  An  instrument 
known  as  the  psychrophore,  or  a  Meschung  sound,  by  means  of 
which  cold  can  be  applied  to  the  prostatic  urethra,  has  been  recom- 
mended in  the  treatment  of  such  cases  by  manv  writers.  .  It  is 
somewhat  inconvenient  to  use,  and  probably  gives  no  better  results 
than  can  be  obtained  from  the  use  of  the  other  methods  previ- 
ously mentioned.  Above  all,  sexual  continence  or  the  regulation 
of  the  sexual  life,  as  by  marriage,  is  to  be  recommended. 

If  the  functional  disturbances  are  due  to  new-growths,  ulcera- 
tion, gangrene,  too  short  a  frenum,  or  other  malformation,  proper 
surgical  treatment  should  be  instituted.  Sterility  is  not  infre- 
quently due  to  the  past  effects  of  a  double  epididymitis,  but  cases 
due  to  malformation  have  also  occurred.  Gyurkowcht^^'s  exami- 
nation of  6000  young  men,  however,  showed  malformations  pres- 
ent in  only  three. 

Where  a  double  orchi-epididymitis,  causing  a  stenosis  of  the  vas 
deferens,  is  responsible  for  sterility,  an  operation  for  its  relief 
may  be  performed ;  this  is  done  by  anastomosing  the  vas  deferens 
by  an  incision  about  three-fourths  of  an  inch  long  with  the  back  of 
the  epididymis.  This  operation  is  difficult  to  perform  on  account 
of  the  small  caliber  of  the  vas  deferens.  A  small  buttonhole  may 
be  made  in  the  vas,  and  a  suture  run  through  each  angle,  uniting 
with  the  incision  in  the  epididymis.  This  operation  has  been  per- 
formed in  comparatively  few  cases,  and  complete  reports  concern- 
ing it  have  not  been  published ;  it  seems,  however,  to  have  been 
successful  in  some  cases. 

It  should  be  remembered  that  in  some  cases  a  previous  organic 
lesion  of  the  deep  urethra  may  have  been  treated  and  cured,  and 
yet  later,  for  some  reason,  a  general  neurasthenia  may  develop. 
Such  patients  would  belong  to  class  2,  and  should  be  referred  to 
the  family  physician  or  to  the  neurologist  for  treatment. 

Class  2. — As  in  this  class  of  patients  the  disorder  is  due  to  a 
general  defect  or  to  a  disturbance  of  the  nervous  system,  it 
embraces  those  in  whom  the  functions  of  the  sexual  apparatus 


646  SEXUAL    NEUROSES 

are  disorganized  because  of  some  diseased  condition  organically 
independent  of  the  sexual  organs.  General  acute  diseases,  such 
as  typhoid  fever  and  pneumonia,  or  the  chronic  general  diseases, 
such  as  nephritis,  malaria,  and  conditions  in  which  there  is  in- 
volvement of  the  spinal  cord,  as  locomotor  ataxia,  myelitis,  and  the 
like,  may  interfere  with  the  sexual  functions.  This  is  especially 
evident  in  certain  drug  habits,  as  in  alcoholism,  morphinism,  and 
the  like.  Certain  psychic  causes  would  also  come  under  this  head, 
e.  g.,  psychic  paresthesia,  which  may  provoke  seminal  emissions 
without  erection.  Preponderance  of  psychic  inhibition,  insuf- 
ficient stimulation  of  excitable  centers,  or  sudden  disturbances  of 
reflex  action  may  all  tend  to  disturb  the  sexual  function.  The 
various  forms  of  intoxication,  as,  for  example,  diabetes  and  lead- 
poisoning,  could  be  considered  as  coming  under  this  head,  and 
may  tend  to  cause  functional  disturbances  or  impotence,  and 
cause  the  libido  to  be  retained. 

It  is  very  interesting  to  observe  how  carefully  and  dogmati- 
cally some  writers,  particularly  the  Germans,  have  classified  these 
various  causes,  which,  after  all,  are  only  conjectural,  attributing 
impotence  to  too  small  a  center  in  the  brain  to  cause  the  proper 
reflex  activity  that  gives  rise  to  erection,  or  to  too  weak  a  stimula- 
tion in  the  brain  center  supposed  to  regulate  the  sexual  act.  Al- 
though, as  previously  stated,  the  treatment  of  this  class  of  patients 
should  properly  be  relegated  to  the  family  physician  or  the  neurol- 
ogist, the  surgeon  should,  nevertheless,  be  sufficiently  familiar 
with  mental  and  nervous  diseases  to  be  able  to  differentiate  them 
from  organic  disease  of  the  sexual  apparatus.  The  mistake  is 
frequently  made  of  overlooking  organic  diseases  of  the  spinal  cord. 

Treatment  will  necessarily  consist  primarily  in  the  elimination 
of  the  causative  factors. 

Class  3. — This  being  a  mixed  class,  in  which  there  is  a  combina- 
tion of  general  or  mental  disorders  with  the  presence  of  actual 
lesions  in  the  genito-urinary  tract,  the  diagnosis  is  particularly 
difficult.  There  may  be  two  or  three  different  factors  at  work, 
and  these  belong  in  class  i  or  2.  As  fairly  representative  of  this 
third  class  may  be  mentioned  the  not  uncommon  case  of  a  man 
with  a  slight  chronic  posterior  urethritis,  whose  mind  is  immovably 
fixed  on  his  urethra,  to  the  exclusion  of  all  else;  or  that  of  a  man 


SEXUAL    NEUROSES  647 

suflfering  from  some  general  disease,  such  as  neurasthenia,  due  to 
malaria,  lead-poisoning,  or  the  early  stages  of  tuberculosis.  Such 
a  patient  generally  presents  evidences  of  some  slight  organic  dis- 
ease, most  often  of  the  deep  urethra,  and  this  is  not  infrequently 
overtreated  and  too  little  attention  given  to  the  constitutional 
disorder.  On  the  other  hand,  when  the  treatment  is  undertaken, 
enough  attention  may  not  be  given  to  the  symptoms  in  the  urinary 
tract,  all  the  efforts  being  directed  toward  improving  the  patient's 
general  condition. 

In  this  class  of  cases  the  prognosis  as  regards  the  recovery  of 
loss  of  function  of  the  sexual  apparatus  is  dependent  upon  so 
many  factors  that  no  general  statement  can  be  made.  In  these 
patients,  more  than  in  those  of  the  other  two  classes,  success  is 
largely  the  result  of  good  judgment  and  skilful  treatment  by  sur- 
geon or  physician.  When  the  varying  causes  that  play  a  part  in 
the  disturbance  can  be  ascertained,  the  physician  may  be  able  to 
institute  a  course  of  treatment  that  will  restore  the  normal  condi- 
tion, whereas  the  surgeon,  confined  to  a  narrower  field,  might  be 
unable  to  accomplish  equal  results.  . 

Obviously,  no  definite  general  plan  of  treatment  can  be  laid 
down  for  patients  of  this  class.  The  case  must  be  treated  as  a 
whole,  attention  being  first  directed  to  the  dominant  conditions. 
Incidentally  all  local  lesions  of  an  irritative  character  should  re- 
ceive proper  local  or  general  treatment;  there  is,  however,  no 
more  severe  test  of  the  physician's  judgment  and  ability  than  is 
demanded  for  the  successful  management  of  these  cases. 


NDEX 


Abdominal  nephrectomy,  305 
Abscess  of  Cowper's  glands,  474 
treatment,  475 
of  Littre's    glands   after   urethritis, 

421 
of  prostate,  557 

treatment,  557 
perinephritic,  189 
peri-urethral,  in  female,  492 
Absence  of  kidney,  247 
Acetone  in  urine,  118 
Acid,  phosphoric,  in  urine,  1 16 
sulphuric,  in  urine,  116 
uric,  115,  158 
urine,  substances  in,  125 
Actinomyces  fungi  in  urine,  128 
Adenocarcinoma  of  bladder,  353 
Adenocytoma,  papillomatous,  of  tes- 
ticle, 609 
Adenoma  of  kidney,  259 

of  testicle,  610 
Afferent  artery,  154 
After-care,  postoperative,  90 
Albarran's  incision  for  exploration  of 
kidney,  292 
for  removing  prostate,  579 
for   repairing   bladder  wall   after 

suprapubic  cystotomy,  357 
for  suturing  urethra,  474 
Albuminuria,  116 

exophthalmos  in,  1 75 
Alexander's    operation    for    hypertro- 
phy of  prostate,  564 
Alkaline  urine,  substances  in,  127 
Amaurosis,  uremic,  177 
Amblyopia,  uremic,  177 
Ammonio-magnesium     phosphate     in 

urine,  127 
Ammonium  urate  in  urine,  127 
Amputation  of  penis,  509 

in  continuity,  511 
Amyloid  casts  in  urine,  124 
Anastomosis,  lateral,  of  ureters,  334 
Israel's  operation,  334 
rectal,  of  ureters,  347 
Anemia  in  nephritis,  167 
treatment  of,  169 
of  prostate,  535 
Anesthesia,  99 


Anesthesia,  conduction,  100 
Legueu's  needles  for,  103 

local,  100 

nausea  after,  107 

rectal,  100 

spinal,  100 
Angioma  of  kidney,  279 
Anomalies  in  arterial  supply  of  kid- 
neys, 250 
Antiformin  test  for  tubercle  bacillus 

in  urine,  241 
Anuria  after  operation,  108 

opening  and  draining  pelvis  of  kid- 
ney for,  317 
Aplasia  of  bladder,  344 
Arnott's  probe,  470 
Arteria  rectae,  153 
Arterial  arcade  of  kidney,  153 

supply    of    kidneys,    anomalies    in, 
250 
Arteries,  helicine,  515 
Artery,  afferent,  154 

efferent,  154 
Atony  of  bladder,  346 

treatment,  346 
Atrophy  of  testicle,  600 
treatment  of,  634 


Bacillus,  colon,  in  urine,  128 

green-pus,  in  urine,  127 

proteus,  in  urine,  128 

smegma,  in  urine,  128 

timothy  hay,  in  urine,  128 

tubercle,  in  urine,  128 

antiformin  test  for,  241 
Bacteria,  Gram's  method  of  staining, 

131 
in  urine,  127 

as  cause  of  suppurative  nephritis, 
188 
Bacterial  content  in  gonorrheal  ure- 
thritis, 135 
in  simple  urethritis,  133 
Balanitis  praeputialis,  514 
Bandage,  scrotal,  620,  621 
method  of  applying,  98 
triangular,    method    of   forming, 
98 

649 


650 


INDEX 


Beck's  operation  for  hypospadias  of 
glans,  504 
for  scrotal  hypospadias,  507 
Bertini's  columns,  152 
Bessel-Hagen's   operation   for   plastic 
repair   of    denudations    of    skin    of 
penis,  498 
Sevan's  operation  for  inguinal  reten- 
tion of  testicle,  631 
Bierhoff  cystoscope,  70 

modification      of      Nitze-Albarran 

cystoscope,  75 
supports  for  legs  in  cystoscopy,  65 
Bigelow's  evacuator,  368 

lithotrite,  368 
Bile-pigments  in  urine,  119 
Bismuth  in  x-ray  diagnosis  of  bladder 

diseases,  52 
Bistoury,  Gouley's  471 
Bladder,  abnormities  in  shape  and  size 
of,  345 
adenocarcinoma  of,  353 
anatomy  of,  343 
aplasia  of,  344 
atony  of,  346 

treatment,  346 
blood-supply  of,  344 
carcinoma  of,  353 
continuous    catheterization    of,    in 

Bright's  disease,  316 
curettage  of,  in  chronic  cystitis,  375 
dilatation  of,  345 
diseases  of,  344 
diagnosis,  355 
treatment,  355 
distortion  of,  345 
diverticulum  of,  345,  410 
epithelioma  of,  343 
evacuator      and      obturator,   Chis- 

more's,  370 
exstrophy  of,  344 

Bottomley's  operation  for,  402 
diagnosis,  397 

Harrison's  operation  for,  404 
Maydl's  operation  for,  398-400 
Segond's  operation  for,  401-403 
Sonnenberg's  operation  for,  396, 

397 
treatment,  397 
extirpation  of,  total,  407 
fibroma  of,  352 

foreign  bodies  in,  diagnosis  of,  395 
cystoscopic  appearances  in,  60 
treatment  of,  395 
hernia  of,  408 
diagnosis,  408 
treatment,  409 
inflammation    of,     348.     See     also 

Cystitis. 
injuries  of,  diagnosis,  404 
treatment,  405 


Bladder,  irrigation,  continuous,  after 

operation,  1 1 1 
malformations  of,  acquired,  346 

congenital,  344 
mucous  coat  of,  344 
muscular  coat  of,  343 
myoma  of,  352 
myxoma  of,  352 
nerve-supply  of,  344 
papilloma  of,  351 
pathology  of,  344 
perforations  of,  346 
physiology  of,  343 
puncture  of,  374 
resection  of,  391,  392 
rupture  of,  345,  405 

diagnosis,  405 

treatment,  406 
sarcoma  of,  354 
serous  coat  of,  343 
stone  in,  cystoscopic  appearances  in, 
68 

diagnosis  of,  364 

litholapaxy  for,  368 

remarks  on  removal  of,  374 

suprapubic  cystotomy  for,  376 
lateral  incision,  384 

symptoms  of,  365 

treatment  of,  364 
submucous  coat  of,  344 
syphilitic  disease  of,  350,  354 

cystoscopic  appearance  in,  66 
tumors  of,  350 

cystoscopic  appearances  in,  68 

diagnosis,  388 

innocent,  351 

malignant,  352 

treatment,  388 
ulcers  of,  395 
wounds  of,  diagnosis,  404 

treatment,  405 
Blindness,  uremic,  177 
Blood  in  acute  nephritis,  167 

in  chronic  interstitial  nephritis,  168 
in  diseases  of  kidney,  163 
in  nephritis,  166,  167 
in  new-growths  of  kidney,  167 
in  parenchymatous  nephritis,  167 
in  tubercular  nephritis,  166 
in  uremia,  168 
Blood-casts  in  urine,  124 
Blood-corpuscles,  red,  in  urine,  124 
Blood-pressure  and  pulse  chart,  172 

in  diseases  of  kidney,  170 
Blood-supply  of  bladder,  344 
of  kidney,  150 

minute  anatomy,  153 
of  testicles  and  epididymis,  599 
Bottomley's  operation  for  exstrophy 

of  bladder,  402 
Bougie,  Greene's,  463 


INDEX 


651 


Bougies,  37 
a  boule,  39 
filiform,  37 
Bowels,   condition   of,   in   examining, 

20 
Bowman's  capsule,  147,  152 
Bridge    for    support    of    scrotum    in 

epididymitis,  619 
Bright's  disease,  194 

acute,  pathology  of,  195 
symptoms  of,  206 
treatment  of,  212 
chronic     degenerative     type     of, 
pathology,  205 
diagnosis  of,  208 
food  in,  221 

personal  hygiene  in,  218 
treatment  of,  217 
continuous      catheterization      of 

bladder  in,  316 
course  of,  206 
diagnosis  of,  206 
operative  treatment  of,  316 
pathology  of,  194 
prognosis  of,  210 
symptoms  of,  206 
treatment  of,  212 
surgical,  316 
Bryson's   operation   for   hypertrophy 

of  prostate,  568 
Bubo,  500 


Cachexia  in  cancer  of  prostate,  590 
Calcium  carbonate  in  urine,  127 
oxalate  crystals  in  urine,  126 
Calculus  in  urethra,  501 
prostatic,  559 
renal,  268 

diagnosis,  273 
nephrotomy  for,  302 
pathology,  268 
pyelotomy  for,  303 
symptoms,  272 
treatment,  274 
ureteral,  322 

operations  for,  341 
vesical,  diagnosis  of,  364 
litholapaxy  for,  368 
remarks  on  removal  of,  374 
suprapubic  cystotomy  for,  376 

lateral  incision,  384 
symptoms  of,  365 
treatment  of,  364 
Calices  of  kidney,  152 
Capsule,  fibrous,  of  kidney,  151 

of  Bowman,  147 
Caput  gallinaginis,  532 
Carcinoma,  chimney-sweep's,  610 
of  bladder,  353 
of  female  urethra,  494 


Carcinoma  of  kidney,  280 

of  penis  and  gumma  of  penis,  dif- 
ferentiation, 511 
of  prostate,  588 
age  occurring,  590 
cachexia  of,  590 
frequency  of,  588 
hematuria  in,  592 
pain  in,  591 

physical  examination  in,  592 
prognosis,  594 
treatment  of,  594 
curative,  595 
palliative,  594 
preventive,  594 
of  testicle,  610 
Caruncles  of  female  urethra,  495 
Castration,  628 
Casts,  amyloid,  in  urine,  124 
blood-,  in  urine,  124 
epithelial,  in  urine,  124 
fatty,  in  urine,  124 
granular,  in  urine,  124 
hyaline,  in  urine,  124 
in  urine,  123 
pus-,  in  urine,  124 
waxy,  in  urine,  124 
Catarrhal  cystitis,  349 
urethritis,  acute,  417 
chronic,  417 
Catheter  after  operation,  no 

Hutchinson's,    for    applying    oint- 
ments to  urethra,  439 
life,  565 
Malecot,  27 
Mercier's,  460 
bicoude,  35 
coude,  35 
Pezzer,  37 
Ultzmann's,  43 
Catheterization,  43 

continuous,  of  bladder,  in  Bright's 

disease,  316 
method  of  passing  instrument  in,  44 
of  ureters,  70 

with  reverse  cystoscope,  75 
with  ureteral  catheter  cystoscope 
of  straight  type,  72 
Catheters,  33 

Cells,    epithelial,    in    gonorrheal   ure- 
thritis, 134 
in  simple  urethritis,  132 
pus-,  in  gonorrheal  urethritis,   134 

in  urine,  121 
sustentacular,  597 
Cercomonas  intestinalis  in  urine,  128 
Cerebral   hemorrhage,    postoperative, 

106 
Cervical  secretion,  examination  of,  143 
Chancre  of  penis,  500 
Chancroid  of  penis,  500 


652 


INDEX 


Chemic  composition  of  urine,  157 
Chimney-sweep's  cancer,  610 
Chismore's    bladder    evacuator     and 
obturator,  370 

evacuating  lithotrite,  369 
Chlorids  in  urine,  115 
Chondroma  of  testicle,  610 
Chyluria,  1 19 
Circumcision,  516 

in  adult,  517 
Cloudy  urine,  31 
Collecting  tubule  of  kidney,  153 
Colon  bacillus  in  urine,  128 
Columns  of  Bertini,  152 

of  Sertoli,  597 
Compensation  in   renal   disease,    168 
Compensatory  hyperplasia  of  kidney, 

161 
Complement-fixation     in     gonorrhea, 

144 
Conduction  anesthesia,  100 

Legueu's  needles  for,  103 
Condyloma  of  female  urethra,  495 
Conjugate  sulphates  in  urine,  116 
Conjunctiva,  edema  of,  in  renal  dis- 
eases, 175 
Conjunctivitis,  gonorrheal,  442 
Convoluted  tubules,  597 
Corpora  cavernosa,  392 
Corpus  highmorianum,  596 

spongiosum,  513 
Corpuscles,  red,  in  urine,  120 
Cortex  of  kidney,  151 
Cowperitis,  urethral  exudate  in,  139 
Cowper's  glands,  415 
abscess  of,  474 
treatment,  475 
Crede's     treatment     of     ophthalmia 

neonatorum,  445 
Crisis,  Dietl's,  252 
Crura  of  penis,  412 
Cryptorchidism,  600 
Crystalline  deposits  in  urine,  125 
Crystals,    calcium-oxalate,    in    urine, 

126 
Curettage  of  bladder  in  chronic  cys- 
titis, 375 
Cylindroids,  in  urine,  123 
Cystic  kidney,  248 

tumors  of  testicle,  609 
parasitic,  of  testicle,  609 
Cystin  in  urine,  126 
Cystitis,  348 

acute,  cystoscopic  appearances  in, 
66 
diagnosis  of,  356 
symptoms  of,  356 
treatment  of,  356 

catarrhal,  349 

chronic,     cystoscopic     appearances 
in,  66 


Cystitis,  chronic,  diagnosis  of,  358 
treatment  of,  358 

curettage  of  bladder,  375 
internal,  358 
local,  359 
diagnosis  of,  358 
etiology  of,  348 
gonorrheal,  356 

non-tubercular     ulcerative,     cysto- 
scopic appearances  in,  59 
phlegmonous,  350 
purulent,  349 
treatment  of,  356 
tubercular,  350 

cystoscopic  appearances  in,  68 
diagnosis  of,  361 
treatment  of,  362  ' 

Cystoscope,  Bierhoff's,  70 
Lewis',  71 

Nitze-Albarran,     Bierhoflf's  modifi- 
cation of,  75 
Nitze's,  60 

operating,  64 
operative,  77 
reverse,   catheterization   of   ureters 

with,  75 
Schapira,  77 
universal,  63 
Cystoscopic  appearances,  66 
in  acute  cystitis,  66 
in  chronic  cystitis,  66 
in  enlargement  of  prostate,  69 
in  foreign  bodies  in  bladder,  68 
in  non- tubercular  ulcerative  cys- 
titis, 66 
in  stone  in  bladder,  68 
in  syphilis  of  bladder,  66 
in  tubercular  cystitis,  66  • 

in  tumors  in  bladder,  68 
Cystoscopy,  60 

position  of  patient  in,  63 
practical,  63 
Cystostomy,  385 

Cystotomy,  suprapubic,  for  removal 
of  prostate,  574 
for  stone  in  bladder,  376 
lateral  incision,  384 
Cysts,  dermoid,  of  testicle,  609 
hydatid,  of  kidney,  270 
multilocular,  of  spermatic  coid,  613 
of  ureter,  321 
retention,  of  testicle,  609 


Decapsulation  of  kidney,  315 
Defects,  congenital,  of  prostate,  533 
Dermoid  cysts  of  testicle,  609 
Dietl's  crisis,  252 
Dilatation  of  bladder,  345 
of  female  urethra,  491 
treatment,  491 


INDEX 


653 


Dilators,  Kollmann's,  457 
Displaced  kidney,  251 
Displacements  of  kidney,  247 
Distortion  of  bladder,  345 
Diverticulum  of  bladder,  345,  410 
Double  pj'onephrosis,  185 
Drainage  after  operation,  109 
in  nephrotomy,  299 


EcHiNOCOccus  booklets  in  urine,  128 
Edebohls'   incision  for  nephrectomy, 
310 
in  operations  on  kidney,  390 

method  of  fixation  of  kidney,  295 
of  nephropexy,  295 

pad  for  operations  on  kidneys,  291 
Edema   of  conjunctiva   in  renal   dis- 
eases, 175 

of  eyelids  in  renal  diseases,  1 75 
Efferent  artery,  154 
Elephantiasis  of  scrotum,  613 
diagnosis,  615 
prognosis,  616 
treatment  of,  616 
Embolic  infarction  of  kidney  in  sup- 
purative nephritis,  188 
Encysted    hydrocele    of    cord,    treat- 
ment of,  627 
Endocarditis,  gonorrheal,  452 

treatment,  453 
Endoscope,  Valentine's,  57 
Endoscopy,  56 

Endothelioma  of  testicle,  610 
Epididymectomy,  627 
Epididymis,  anatomy  of,  596 

blood-supply  of,  599 

body  of,  598 

head  of,  598 

lymphatics  of,  599 

nerve-supply  of,  599 

tail  of,  598 
Epididymitis,  605 

acute,  606 

bridge  for  support  of  scrotum  in, 
619 

chronic,  606 

diagnosis  of,  606 

medicinal  treatment  of,  617 

symptoms  of,  606 
Epispadias,  508 

Thiersch's  operation  for,  508 
Epithelial  casts  in  urine,  124 

cells  in  gonorrheal  urethritis,  134 
in  simple  urethritis,  132 
Epithelioma  of  bladder,  353 
Epithelium  in  urine,  121 
Erythrocytes  in  urine,  120 
Evacuator,  Bigelow's,  368 
Examination,      caliber      of      urinary 

stream  in,  2? 


Examination,  character  of  urine  in,  23 
condition  of  bowels  in,  20 
diminished      amount      of     urinary 

excretion  in,  21 
history  of  previous  diseases  in,  24 
incontinence  of  urine  in,  23 
inspection  in,  25 
instrumental,  32 
of  kidney,  70 
methods  of,  17 
microscopic,  of  urine,  119 
micturition  in,  20 
of  kidneys  for  diagnostic  purposes, 

288 
of  prostate,  28 
of  secretions,  30 
of  urethral  exudate,  128 
of  urine,  112 
of  vagina,  20 
physical,  26 
questions  in,  17-19 
sexual  life  in,  25 
urethral  discharge  in,  20 
urinary  retention  in,  23 
Exophthalmus    in    albuminuria,    175, 

176 
Experimental   polyuria   test   for   per- 
meability of  kidriey,  81 
Exploration  of  kidney,  Albarran's  in- 
cision for,  294 
operations  for,  291 
postmortem  incision  for,  294 
Exstrophy  of  bladder,  344 

Bottomley's  operation  for,  402 
diagnosis,  397 

Harrison's  operation  for,  404 
Maydl's  operation  for,  398-400 
Segond's  operation  for,  401-403 
Sonnenberg's  operation  for,  396, 

397 
treatment  of,  397 
Extirpation  of  bladder,  total,  407 
Exudate,  examination  of,  from  female 
genitals,  142 
urethral,  examination  of,  128 

in  chronic   gonorrheal   urethritis, 

136 
in  Cowperitis,  139 
in  gonorrheal  urethritis,  133 
in  prostatitis,  137 
in  simple  urethritis,  132 
in  vesiculitis,  138 
purulent,  129 
Eye,    gonorrhea    of,    from   urethritis, 
442 
prognosis,  443 
symptoms,  443 
treatment,  443 
hemorrhage  of,  in  renal  diseases,  175 
EyeHds,  edema  of,  in  renal  diseases, 
175 


654 


INDEX 


Fat  in  urine,  119 
Fatty  casts  in  urine,  124 
Female  genitals,  examination  of  secre- 
tions and  exudates  from,  142 
Fenwick's    operation    of    suprapubic 

enucleation  of  prostate,  576 
Fibroma  of  bladder  wall,  352 
of  kidney,  278 
of  prostate,  587 
of  testicle,  610 

polypoid,  of  female  urethra,  496 
Fibrous  capsule  of  kidney,  151 
Filaria  sanguinis  hominis  in  urine,  128 
Filiform  bougies,  37 
Fistula  of  kidne}',  operation  for,  313 
of  ureter,  324 

perirenal,  operation  for,  313 
urethral,     in     pendulous     urethra, 
operation  for,  479 
operations  for,  479 
perineal,  operations  for,  480 
urethrorectal,  diagnosis,  482 
operations  for,  481 
prognosis,  482 
treatment,  482 
local,  483 
operative,  484 
palliative,  483 
Tuttle's  operation  for  closure  of, 
484 
urethrorectoperineal,  diagnosis,  482 
operations  for,  481 
prognosis,  482 
treatment,  482 
local,  483 
operative,  484 
palliative,  483 
Floating  kidney,  250 

fixation  of,  294 
Forceps,  Thompson's  urethral,  501 
Foreign    bodies    in    bladder,     cysto- 
scopic  appearances  in,  68 
diagnosis  of,  407 
treatment  of,  407 
in  urethra,  501 
Formaldehyd  sterilizer,  92 
Fossa  navicularis,  416 
Fractures  of  penis,  499 
Fragments  of  tumors  in  urine,  122 
Freyer's   method    of   removing   pros- 
tate, 577 
tube,  383 
Fulguration,  78 

Fuller's  incision  for  removal  of  semi- 
nal vesicles,  526,  528 
Fungi,  actinomyces,  in  urine,  128 
Fusion  of  kidney's,  247 


Genitals,    female,    examination    of 
secretions  and  exudates  from,  142 


Genito-urinary   system,   neuroses   of, 
640 
prognosis,  644,  647 
treatment,  644,  646,  647 

Geographic  conditions  in  examination, 

24 
Gerachty    and    Rowntree's    test    for 

permeability  of  kidney,  82 
German    method    of    abortive    treat- 
ment of  urethritis,  429 
Gersuny   and   Witzel's   operation   for 

inguinal  retention  of  testicle,  633 
Glands,  Cowper's,  415 
abscess  of,  474 
treatment,  475 

Littre's,  416 

abscess  of,  after  urethritis,  421 

Tyson's,  414 
Glans  penis,  413 
Glass  syringes,  42 

tests  for  locating  seat  of  urethritis, 

31,  425 
Globus  major,  598 
Glomerulus,  148 
of  kidney,  154 
Goldhom's  stain  for  spirochata  pal- 
lida, 145 
Goldsmith     irrigation     urethrocysto- 

scope,  60 
Gonococcus,    biologic    characteristics 
of,  418 
in  gonorrheal  urethritis,  134 
in  urine,  127 

vaccine    treatment    of    gonorrheal 
rheumatism  and  epididymitis,  45 1 
Gonorrhea  of  eye  from  urethritis,  442 
prognosis,  443 
symptoms,  442 
treatment,  443 
of  mouth  from  urethritis,  442 
of  rectum  from  urethritis,  442 
Gonorrheal  conjunctivitis,  442 
cystitis,  356 
endocarditis,  452 
treatment,  453 
iritis,  446 
rheumatism,  447 
causes,  447 
course,  448 
diagnosis,  449 
prognosis,  449 
treatment,  450 
urethritis,  417.    See  also  Urethritis. 
Gorget,  Teale's,  457 
Gouley's  bistoury,  471 

points  of  whalebone  guides,  462 
sound  and  guide,  461 
Gram-negative  organisms,  132 
Gram-positive  organisms,  132 
Gram's  method  of  staining  bacteria, 
13T 


Granular  casts  in  urine,  124 

Gravity,  specific,  of  urine,  113 

Greene   and   Brooks'   abortive   treat- 
ment of  urethritis,  428 

Greene's  bougie,  463 

Green-pus  bacilli  in  urine,  127 

Gumma  of  kidney,  245 

of  penis  and  cancer  of  penis,   dif- 
ferentiation, 511 

Guyon's  tube,  383 


Harrison's   operation   for   exstrophy 

of  bladder,  404 
Hay  bacilli,  timothy,  in  urine,  128 
Hayden-Janet  syringe,  42 
Helicine  arteries,  413 
Hematoma  of  spermatic  cord,  613 

treatment,  613 
Hematuria  in  cancer  of  prostate,  592 
Hemorrhage,    cerebral,    after    opera- 
tions, 106 

in  nephrectomy,  310 

of  eye  in  renal  diseases,  175 
Henle's  ascending  loop,  153 

descending  limb,  153 

loop,  153 
Hernia  of  bladder,  408 
diagnosis,  408 
treatment,  408 
Hodgkin's  disease,  tumor-like  masses 

in  kidney  in,  281 
Horseshoe  kidney,  248 
Hutchinson's    catheter    for    applying 

ointments  to  urethra,  439 
Hyaline  casts  in  urine,  128 
Hydatid  cysts  of  kidney,  277 
Hydrocele,  611 

acute,  612 

chronic,  582 

encysted,  treatment  of,  627 

operation  for,  620 

tapping  of,  621 
Hydronephrosis,  253 

acquired,  256 

congenital,  255 

diagnosis,  258 

etiology,  254 

in     predisposing     to     suppurative 
nephritis,  187 

pathologic  anatomy,  258 

results,  262 

surgery  of,  327 

symptoms,  258 

treatment,  259 

Trendelenburg's  operation  for,  331 
Hydronephrotic  sac,  resection  of,  334 
Hyperemia  of  prostate,  535 
Hypernephroma,  281 

of  prostate,  587 

of  testicle,  610 


INDEX  655 

Hyperplasia,    compensatory,    of    kid- 
ney, 161 
Hypertrophy  of  prostate,  537 

Alexander's  operation  for,  568 
Bryson's  operation  for,  568 
cystoscopic  appearances  in,  69 
diagnosis,  560 
operations  for,  568 
pathology  of,  539 
symptoms  of,  538,  562 
treatment  of,  563 
operative,  568 
Hypochondriasis    in    chronic    prosta- 
titis, 554 
Hypoplasia  of  testicle,  599 
Hypospadias,  502 

of  glans.  Beck's  operation  for,  506 

operations  for,  505 

scrotal.  Beck's  operation  for,  506 

operations  for,  506 
varieties,  504 


ICHTHYOi.  in  tubercular  cystitis,  362 
Incision,  Albarran's,  for  exploration  of 
kidney,  294 
Edebohls',  for  nephrectomy,  310 
in  operations  on  kidney,  290 
for  removal  of  seminal  vesicles, 
526,  528 
Israel's,    in    operations   on   kidney, 
290 
for  nephrectomy,  310 
Kocher's,   for    removal    of   seminal 

vesicles,  525,  527 
Kraske's,    for    removal    of   seminal 
vesicles,  524,  527 
Rydygier's       modification 
of,  527 
loin,  in  operations  on  kidney,  290 
postmortem,  for  exploration  of  kid- 
ney, 294 
Senn's,  for  removal  of  seminal  vesi- 
cles, 526,  527 
transverse,  in  operations  on  kidney, 

290 
von  Dittel's,  for  removal  of  seminal 

vesicles,  525,  527 
Zuckerkandl's,  for  removal  of  semi- 
nal vesicles,  525,  527 
Incontinence  of  urine  in  children,  347 

in  examining,  23 
Indican  in  urine,  119 
Indigo-carmin    test    for    permeability 
of   kidney    associated    with    ureter 
catheterization,  87 
Infarction,    embolic,    of    kidnej-,    in 
suppurative  nephritis,  188 
of  kidney  in  acute  infectious  dis- 
eases, 181 
uric-acid,  271 


656 


INDEX 


Infectious  diseases,  acute,  diseases  of 
kidney  in,  diagnosis  of, 
183 
prognosis  of,  184 
treatment  of,  184 
infarction  of  kidney  in,  181 
kidney  in,  179 

nephritis  in,  prognosis  of,  183 
treatment  of,  182 
Inflammation   of   bladder,    348.     See 
also  Cystitis. 
of  ureters,  321 
Inguinal  retention  of   testicle,   treat- 
ment for,  631 
Inspection  in  examination,  25 
Instrumental  examination,  32 

of  kidney,  70 
Instruments,  urethral,  care  of,  90 
lubricants  for,  94 
sterilization  of,  91 
Interstitial   nephritis,    chronic,   blood 

in,  168 
Iritis,  gonorrheal,  446 
Israel's  incision  for  nephrectomy,  310 
in  operations  on  kidney,  290 
method   of   lateral   anastomosis   of 
ureter,  334 


Janet  syringe,  42 

Janeway's   sphygmomanometer,    170, 
171 


Katheterpurine,  95 
Keetly's  operation  for  inguinal  reten- 
tion of  testicle,  631 
Kidney,  147 
absence  of,  247 
adenoma  of,  279 
Albarran's  incision  for  exploration 

of,  294 
anatomy  of,  148 
angioma  of,  279 
arterial  arcade  of,  153 

supply  of,  anomalies  in,  250 
blood-supply  of,  150 

minute  anatomy,  153 
calices  of,  152 
carcinoma  of,  280 
collecting  tubule  of,  153 
compensatory  hyperplasia  of,  161 
congenital  lobulation  of,  247 
cortex  of,  151 
cystic,  248 
decapsulation  of,  315 
diseases  of,  blood  in,  163 

blood-pressure  in,  1 70 

compensation  in,  158 

edema  of  conjunctiva  in,  175 
of  eyelids  in,  175 


Kidney,   diseases  of,   hemorrhage  of 
eye  in,  175 

in  acute  infectious  diseases,  diag- 
nosis of,  183 
prognosis  of,  184 
treatment  of,  184 

ocular  manifestations,  175 
displacements  of,  247,  251 
distal  tube  of,  153 
embryology  of,  147 
examination  of,  for  diagnosis,  288 
fibroma  of,  277 
fibrous  capsule  of,  151 
fistula  of,  operation  for,  313 
floating,  250 

fixation  of,  294 
fusion  of,  247 
glomerulus  of,  154 
gumma  of,  245 
horseshoe,  248 
hydatid  cysts  of,  277 
in  acute  infectious  diseases,  179 
in  syphilis,  244 
infraction    of,    in    acute    infectious 

diseases,  181 
injuries  of,  263 

prognosis,  265 

treatment,  266 
instrumental  examination  of,  70 
irregular  tubule  of,  153 
labyrinth  of,  151 
lesions  of,  in  uremia,  228 
lipoma  of,  278 
lymphatics  of,  150 
malformations  of,  247 

congenital,  247 
malposition  of,  congenital,  248 
medulla  of,  151 
medullary  rays  of,  151 
movable,  250 

diagnosis  of,  251 

Dietl's  crisis  in,  252 

fixation  of,  294 

Edebohls'  method,  295 

pathology  of,  250 

treatment,  252 
myoma  of,  279 
new-growths  of,  blood  in,  167 
operations  for  exploration  of,  291 
operations  on,  288 
papilloma  of,  279 
pelvis  of,  152 

lavage  of,  318 
permeability    of,     associated    with 
ureter      catheterization, 
86 
indigo-carmin  test  for,  87 
water  test,  87 

experimental    polyuria    test    for, 
81 

methylene-blue  test  for,  81 


INDEIX 


657 


Kidney,  permeability  of,  nitrogen  test, 
81 
phenolsulphone-phthalein        test 

for,  82 
phloridzin  test  for,  85 
tests  for,  80 
physiology  of,  154 
postmortem  incision  for  exploration 

of,  294 
proximal  convoluted  tubule  of,  153 
pyramids  of,  152 
rhabdomyoma  of,  279 
sarcoma  of,  280 
second  tube  of,  153 
sensory  nerve-supply  of,  151 
spiral  tube  of,  153 
stone  in,  268 
diagnosis,  273 
nephrotomy  for,  302 
pathology,  268 
pyelotomy  for,  303 
symptoms,  272 
treatment,  274 
suppurative    diseases    of,    polynu- 

clear  leukocytosis  in,  166 
surgery  of,  288 
tuberculosis    of,    237.        See    also 

Tuberculosis  of  kidney. 
tumor-like   masses   in,   in   lympho- 
sarcoma, 281 
tumors  of,  289 
diagnosis,  283 
nephrectomy  in,  314 
treatment,  287 
wounds  of,  261 
prognosis,  261 
treatment,  262 
Kinks  of  ureters,  262 
Knife,  Rand's,  469 

Kocher's  incisions  for  removal  of  semi- 
nal vesicles,  525,  527 
Kollmann's  dilators,  457 

method  of  diagnosing  urethritis,  425 
probe,  58 
Kraske's  incision  for  removal  of  semi- 
nal vesicles,  524,  527 
Rydygier's       modification 
of,  524,  527 
Kiister's    operation    for    stricture    of 
ureter,  331 


Labyrinth  of  kidney,  151 

Lacunae  of  Morgagni,  416 

Lavage  of  pelvis  of  kidney,  318 

Legueu's  needles  for  conduction  anes- 
thesia, 103 

Leucin  in  urine,  126 

Leukocytes  in  urine,  121 

Leukocytosis,  polynuclear,  in  suppu- 
rative diseases  of  kidney,  166 

42 


Lewis'  dilating  bulb,  71 

double  ureter-cystoscope,  71 
Lipoma  of  kidney,  278 
Litholapaxy,  368 

technic  of,  370 
Lithotrite,  Bigelow's,  368 

Chismore's  evacuating,  369 
Littre's  glands,  416 

abscess  of,  after  urethritis,  523 
Lobulation,  congenital,  of  kidneys,  247 
Local  anesthesia,  100 
Loffler's  methylene-blue  stain,   130 
Loin  incision  in  operations  on  kidney, 

290 
Loop  of  Henle,  153 
Lubricants  for  urethral  instruments, 

94 
Lymphatics  of  kidney,  150 

of  testicles  and  epididymis,  599 
Lymphosarcoma,    tumor-like    masses 

in  kidney  in,  251 


Maisonneuve's  urethrotome,  464 
Malecot  catheter,  37 
Malformations,  congenital,  of  female 
urethra,  488 

of  bladder,  acquired,  345 
congenital,  344 

of  kidney,  247 
congenital,  247 

of  ureters,  321 
Malignant  tumors  of  bladder,  352 
of  female  urethra,  494 

treatment,  495 
of  testicle,  610 
Malpighian  body,  147,  152 
Malposition,    congenital,    of   kidneys, 

248 
Massage,  prostatic,  in  chronic  prosta- 
titis, 550 
Maydl's   operation   for   exstrophy   of 

bladder,  398-400 
Mayo    attachment   to   surgical   table 

for  operations  on  kidney,  291 
Meatotome,  Otis',  454 
Meatotomy,  453 
Meatus  urinarius,  416 

stricture  of,  from  urethritis,  453 
Mediastinum  testis,  596 
Medulla  of  kidney,  151 
Medullary  rays  of  kidney,  151 
Membranous  urethra,  anatomy  of,  41 1 
Mendelism,  18 
Mercier's  bicoude  catheter,  35 

catheter,  460 

coude  catheter,  35 
Meschung's  sound,  644 
Mesonephros,  147 

Metamorphosis,  fatty,  of  testicle,  601 
Metanephros,  147 


658 


INDEX 


Methylene-blue  stain,  Loffler's,   130 
test  for  permeability  of  kidney,  81 
Micro-orchia,  599 

Microscopic  examination  of  urine,  119 
Micturition  in  examining,  20 
Monorchidism,  600 
Morgagni,  lacunae  of,  416 
Mouth,  gonorrhea  of,  from  urethritis, 

442 
Movable  kidney,  250 
diagnosis  of,  251 
Dietl's  crisis  in,  252 
fixation  of,  294 

Edebohls'  method,  295 
pathology  of,  250 
treatment,  252 
Mucus  in  urine,  121 
Murphy's  method  of  proctoclysis  after 

operation,  108 
Myoma  of  bladder,  352 
of  kidney,  279 
of  prostate,  578 
Myxoma  of  bladder,  352 


Nausea  after  anesthesia,  107 
Nephrectomy,  303 
abdominal,  305 
by  morcellement,  313 
Edebohls'  incision  for,  310 
hemorrhage  in,  310 
in  tumors  of  kidney,  314 
Israel  incision  for,  310 
partial,  306 
remarks  on,  309 
transperitoneal,  305 
Nephritis,  acute,  blood  in,  167 
treatment  of,  212 
anemia  in,  167 

treatment  of,  169 
blood  in,  167 

chronic    inflammatory    variety    of, 
pathology,  202 
interstitial,  blood  in,  168 
treatment  of,  217 
in  acute  infectious  diseases,   prog- 
nosis of,  183 
treatment  of,  182 
ophthalmoplegia  in,  1 76 
parenchymatous,  blood  in,  167 
retinitis  in,  176,  177 
suppurative,  184 

bacteria  in  urine  as  cause  of,  178 

causes  of,  184 

diagnosis  of,  190 

embolic  infarction  of  kidney  in, 

188 
hydronephrosis    in    predisposing 

to,  187 
treatment  of,  193 
treatment  of,  212 


Nephritis,  tubercular,  blood  in,  166 
Nephropexy,  294 

Edebohls'  method,  295 
Nephrostomy,  300 
Nephrotomy,  299 

drainage  in,  299 

for  stone  in  kidney,  302 
Nerve-supply  of  bladder,  344 

of  testicles  and  epididymis,  599 

sensory,  of  kidneys,  151 
Neurasthenia    m   chronic   prostatitis, 

554 
sexual,  643 
Neuroses  of  sexual  organs,  640 
prognosis  of,  643,  647 
treatment  of,  642,  643,  647 
New-growths  of  kidney,  blood  in,  150 
Nitrogen  test  for  kidney  permeability, 

81 
Nitze-Albarran  cystoscope,  Bierhoflf's 

modification  of,  75 
Nitze's  cystoscope,  60 

operating  cystoscope,  64 
Nodules,  saddle-shaped,  of  penis,  499 


Occupational  diseases   in   examina- 
tion, 24 
Ocular    manifestations    of    renal    dis- 
eases, 175,  178 
Operations,  after-care  of  patient,  90 
anuria  after,  108 
catheter  after,  110 
cerebral  hemorrhage  after,  106 
continuous  bladder  irrigation  after, 

III 
drainage  after,  109 
Murphy's    method    of    proctoclysis 

after,  108 
pneumonia  after,  107 
preparation  of  patient  for,  96 
Operative  cystoscopes,  77 
Ophthalmia,  gonorrheal,  442 

neonatorum,  445 
Ophthalmoplegia  in  nephritis,  176 
Orchi-epididymitis     from     strain     of 

spermatic  cord,  607 
Orchitis,  acute,  601 
etiologj'  of,  601 
pathologic  anatomy  of,  602 
symptoms  of,  602 
chronic,  603 
syphilitic,  605 

symptoms  of,  605 
tubercular,  604 

medical  treatment  of,  618 
symptoms  of,  605 
Osteoma  of  testicle,  607 
Otis'  meatotome,  454 

metallic  bougie  a  boule,  39 
urethrometer,  40,  465 


inde;x 


659 


Pain  in  cancer  of  prostate,  591 
Papilloma  of  bladder,  351 

of  kidney,  279 
PapiUomatous  adenocystoma  of  testi- 
cle, 609 
Paraphimosis,  511 

treatment  of,  512 
Parasitic    cystic    tumors   of    testicle, 

609 
Parenchj'matous  nephritis,  blood  in. 

167 
Patent  urachus,  410 
treatment,  411 
Pelvis  of  kidney,  152 

lavage  of,  318 
Penis,  497 

amputation  of,  509 
in  continuity,  511 
anatomy  of,  412 
carcinoma  of,  and  gumma  of  penis, 

differentiation,  511 
chancre  of,  500 
chancroid  of,  500 
crura  of,  412 

denudations    of    skin    of,     Bessel- 
Hagen's  operation  for  plas- 
tic repair  of,  498 
Reich's    operation    for    plastic 
repair  of,  498 
fractures  of,  499 
growths  of,  499 
gumma    of,    and    cancer    of    penis, 

differentiation,  511 
injuries  of,  497 

treatment,  497 
saddle-shaped  nodules  of,  499 
tumors  of,  499 
ulcerations  on,  500 
wounds  of,  497 
treatment,  497 
Perforations  of  bladder,  346 
Perineal  hypospadias,  operations  for, 

507 
urethral  fistula,  operations  for,  480 
Perinephritic  suppuration,  189 
Perirenal  fistula,  operations  for,  313 
Peri-urethral  abscess  in  female,  492 
Permeability  of  kidney,  experimental 
polyuria  test  for,  81 
methylene-blue  test  for,  81 
phenolsulphone-phthalein  test  for, 

82 
phloridzin  test  for,  85 
tests  for,  80 
Permeable  urachus,  344 
Pezzer's  catheter,  37 
Phenolsulphone-phthalein  test  for  per- 
meability of  kidney,  82 
Phimosis,  514 

treatment  of,  514 
Phlegmonous  cystitis,  350 


Phloridzin    test    for    permeability   of 

kidney,  85 
Phosphate,    ammonio-magnesium,    in 

urine,  127 
Phosphates,  amorphous,  in  urine,  126 
Phosphorus  in  urine,  116 
Pigments,  bile-,  in  urine,  119 
Pneumonia  after  operations,  107 
Polynuclear  leukocytosis  in  suppura- 
tive diseases  of  kidney,  166 
Polypoid  fibroma  of  female  urethra, 

496 
Polyuria  test,  experimental,  for  per- 
meability of  kidney,  8 1 
Postmortem   incision   for   exploration 

of  kidney,  294 
Potassium,  urates  of,  in  urine,  125 
Preformed  sulphates  in  urine,  116 
Preparation  of  patient  for  operation, 
96 
on  testicle,  96 
for  suprapubic  section,  97 
Probe,  Arnott's  470 

Kollmann's,  58 
Proctoclysis,  Miu-phy's  method,  after 

operation,  108 
Pronephros,  147 
Prostate,  abscess  of,  557 
treatment,  557 

anatomy  of,  532 

anemia  of,  535 

calculus  of,  47 

carcinoma  of,   588.     See  also   Car- 
cinoma of  prostate. 

congenital  defects  of,  533 

diseases    of,    diagnosis    and    treat- 
ment, 546 

examination  of,  28 

fibroma  of,  587 

hyperemia  of,  535 

hypernephroma  of,  587 

hypertrophy     of,     537.     See     also 
Hypertrophy  of  prostate. 

injuries  of,  534 

myoma  of,  587 

physiology  of,  533 

removal  of,  partial,  386 

through      suprapubic      opening, 

574 
Albarran's  method,  579 
Fenwick's  method,  576 
Freyer's  method,  577 
sarcoma  of,  587 
tumors  of,  587 
wounds  of,  534 
Prostatic  massage  in  chronic  prosta- 
titis, 550 
sinus,  414 

urethra,  anatomy  of,  414 
Prostatitis,  535 
acute,  535 


66o 


INDEX 


Prostatitis,  acute,  diagnosis  of,  546 

simptoms  of,  546 

treatment  of,  547 
chronic,  537 

diagnosis  of,  547 

hj'pochondriasis  in,  554 

neurasthenia  in,  554 

prostatic  massage  in,  550 

symptoms  of,  547 

treatment  of,  547 
urethral  exudate  in,  137 
Proteus  bacillus  in  urine,  128 
Psychrophore,  645 
Pulse  in  uremia,  232 
Puncture  of  bladder,  374 
Purulent  cj'stitis,  349 
urethral  discharges,  140 
urethritis,  acute,  418 
Pus,  green,  bacilli  of,  in  urine,  138 
Pus-casts  in  urine,  124 
Pus-cells     in     gonorrheal     urethritis, 

134 

in  urine,  121 
Pyelography,  52 

dangers  of,  54 

thorium  in,  52 

value  of,  54 
Pyeloplication  and  ureter  correction, 

336 
Pyelotomy  for  stone  in  kidney,  303 
Pyonephrosis,  double,  185 
Pyramids  of  kidney,  152 


Radium  treatment  of  bladder  tumors, 

285 
Rand's  tunneled  knife,  469 
Reaction  of  urine,  114 
Rectal  anastomosis  of  ureters,  337 

anesthesia,  100 
Rectum,  gonorrhea  of.  from  urethritis, 

442 
Red  blood-corpuscles  m  urme,  120 
Reich's   operation   for   plastic   repair 
of  denudations  of  skin  of  penis,  498 
Renal  tissue,  152 
Resection  of  bladder,  391,  392 
of  hydronephrotic  sac,  334 
of  urethra,  476 
Rete  testis,  597 
Retention  cysts  of  testicle,  609 

inguinal,  of  testicle,  treatment  for, 

631 
of  urine  after  operation,  108 
from  urethritis,  treatment,  459 
Retinitis  in  nephritis,  166,  167 
Rhabdomyoma  of  kidney,  279 
Rheumatism,  gonorrheal,  447 
causes,  447 
cotnse,  448 
diagnosis,  449 


Rheumatism,    gonorrheal,    prognosis, 
450 
treatment,  450 
Rontgen  rays,  value  in  diagnosis,  51 
Rowntree  and  Gerachty's  test  for  per- 
meability of  kidney,  82 
Rupture  of  bladder,  345,  405 
diagnosis,  405 
treatment,  406 
of  urethra,  472 
diagnosis,  473 
treatment,  473 
Rydygier's   modification   of   Kraske's 
incision    for    removal    of    seminal 
vesicles,  524,  527 

Saddle-shaped  nodules  in  penis,  499 
Salvarsan,  effect  of,  on  kidney,  246 
Sarcoma  of  bladder,  354 

of  female  urethra,  495 

of  kidnej',  280 

of  prostate,  587 

of  testicle,  610 
Schapira  C3'stoscope,  77 
Scrotal  bandage,  620,  621 
method  of  applying,  98 
triangular,    method    of    forming, 

97 
hypospadias,  operations  for,  507 
Scrotum,    bridge    for   support   of,    in 
epididymitis,  619 
elephantiasis  of,  613 
diagnosis,  615 
prognosis,  616 
treatment,  616 
Searcher,  41 

Thompson's,  41 
Secretion,    cervical,    examination    of, 

143 
examination  of,  30 

from  female  genitals,  142 
seminal,  examination  of,  139 
vaginal,  examination  of,  143 
Section,  suprapubic,  preparation  for, 

97 
Sediment,  urmary,  120 
Segond's   operation  for  exstrophy  of 

bladder,  401-403 
Seminal    irrigation    and    drainage    of 
duct  through  vas  deferens,  637 
secretion,  examination  of,  139 
vesicles,  522 

diseases  of  duct,  522 

treatment,  523 
Fuller's   incision   for   removal   of 

duct,  526,  528 
irrigation  and   drainage   of   duct 

through  vas  deferens,  637 
Kocher's  incision  for  removal  of 
duct,  525,  527 


INDEX 


66 1 


Seminal  vesicles,  Kraske's  incision  for 
removal  of  duct,  524 
Rydygier's       modification 
of,  524,  527 
Senn's    incision    for    removal    of 

duct,  526,  527 
von  Dittel's  incision  for  removal 

of,  525,  527 
Zuckerkandl's     incision    for    re- 
moval of,  525,  527 
Seminiferous  tubules,  597 
Senn's  incision  for  removal  of  semi- 
nal vesicles,  526,  527 
Sensory  nerve-supply  of  kidneys,  151 
Separation  of  urine,  79 
Septum  pectiniforme,  412 
Sertoli,  columns  of,  597 
Serum  treatment  of  gonorrheal  rheu- 

•matism  and  epididymitis,  451 
Sexual  life  in  history  of  patient,  25 
neurasthenia,  643 
organs,  neuroses  of,  640 
prognosis,  644,  647 
treatment,  644,  646,  647 
Sinus  pocularis,  415,  532 

prostatic,  414 
Skene's  ducts,  487 
Smegma  bacillus  in  urine,  128 
Sodium,  urates  of,  in  urine,  125 
Sonnenberg's  operation  for  exstrophy 

of  bladder,  396,  397 
Sound,  Meschung,  644 
Sounds,  40 

Specific  gravity  of  urine,  123,  157 
Spermatic  cord,  hematoma  of,  613 
multilocular  cysts  of,  613 
strain       of,       orchi-epididymitis 

from,  607 
torsion  of,  607 
treatment,  607 
duct,  599 
Spermatids,  597 
Spermatocele,  608 
treatment,  608 
Spermatocytes,  597 
Spermatogenesis,  598 
Spermatogonia,  597 
Spermatorrhea,  141 
Spermatozoa  in  urine,  123 
Sphygmomanometer,  Janeway's,  170, 

171 
Spinal  anesthesia,  100 
Spiral  tube  of  kidney,  153 
Spirochseta  pallida,   examination  for, 
144 
Goldhorn's  stain  for,  145 
Staff,  Wheelhouse's,  470 
Stain,  Goldhorn's,  for  spirochsta  pal- 
lida, 145 
Gram's,  for  bacteria.  131 
Lofifler's  methylene-blue,  130 


Staphylococcus  in  urine,  127 
Sterilization  of  lu-ethral  instruments, 

91 
SterUizer,  formaldehyd,  92 
Stone  in  bladder,  cystoscopic  appear- 
ances in,  68 
diagnosis  of,  364 
diagnosis  of,  364 
litholapaxy  for,  368 
remarks  on  removal  of,  374 
suprapubic  cystotomy  for,  376 

lateral  incision,  384 
symptoms  of,  365 
treatment  of,  364 
in  kidney,  268 
diagnosis  of,  273 
nephrotomy  for,  302 
pathology  of,  268 
pyelotomy  for,  303 
symptoms  of,  272 
treatment  of,  274 
in  ureter,  322 

operations  for,  341 
Straight  tubules,  597 
Strain     of     spermatic     cord,     orchi- 
epididymitis from,  607 
Streptococcus  in  urine,  127 
Stricture  of  female  urethra,  490,  492 
diagnosis  of,  490 
treatment  of,  490 
of  meatus  urinatius  from  urethritis, 

453 
of  ureter,  322,  324 

Kiister's  operation  for,  331 
operations  for,  341 
of  urethra  from  urethritis,  422,  454 
location  of,  455 
symptoms  of,  454 
treatment  of,  455 
impassable,       from       urethritis, 
treatment,  459 
Struma   lipomatodes   aberratse   renis, 

281 
Subconjunctival  hemorrhage  in  renal 

diseases,  175 
Sugar  in  urine,  1 1 7 
Sulphates,  conjugate,  in  urine,  116 

preformed,  in  urine,  116 
Sulphtu:  in  urine,  116 
Supernumerary  testicle,  493 
Suppuration,  perinephritic,  189 
Suppurative  diseases  of  kidney,  poly- 
nuclear  leukocytosis  in,  166 
nephritis,  184 

bacteria  in  urine  as  cause  of,  188 

causes  of,  184 

diagnosis  of,  190 

embolic  infarction  of  kidney  in, 

188 
hydronephrosis    in,    predisposing 
to,  187 


662 


INDEX 


Suppurative   nephritis,  treatment  of, 

193 
Suprapubic  cystotomy  for  removal  of 
prostate,  574 
for  stone  in  bladder,  376 
lateral  incision,  384 
section,  preparation  for,  97 
Sustentacuiar  cells,  491 
Syphilis,  kidney  in,  244 
Syphilitic  disease  of  bladder,  350,  354 
ulcers  of  bladder,  395 
orchitis,  605 

sj-mptoms  of,  605 
Syringe,  Hayden-Janet,  42 
Janet's,  42 

Ultzmann's,  for  instillation,  43 
Syringes,  42 
glass,  42 


Tapping  of  hydrocele,  622 
Teal's  gorget,  467 

Test,  antiformin,  for  tubercle  bacillus 
in  urine,  241 
experimental     polyuria,     for     per- 
meability' of  kidnej^  81 
glass,  for  locating  seat  of  urethritis, 

31.  425 
methylene-blue,     for     permeability 

of  kidnej-,  81 
phenolsulphone-phthalein,   for  per- 
meability of  kidney,  82 
phloridzin,     for     permeability     of 

kidnej-,  85 
Testicle,  adenoma  of,  610 
anatomy  of,  596 
atrophy  of,  600 

treatment,  634 
benign  tumors  of,  609 
blood-supply  of,  599 
carcinoma  of,  610 
chondroma  of,  610 
cystic  tumors  of,  609 
defects  of,  599 
dermoid  cysts  of,  609 
diseases  of,  pathologj-,  599 

treatment,  617 

therapeutic  measures,  617 
endothelioma  of,  610 
fatty  metamorphosis  of,  601 
fibroma  of,  610 
hypernephroma  of,  610 
hj-pertrophy  of,  600 
hypoplasia  of,  599 
inguinal  retention  of,  treatment  for, 

631 
injiuries  of,  treatment,  634 
lymphatics  of,  599 
malignant  tumors  of,  610 
nerve-supply  of,  599 
operations  on,  preparation  for,  90 


Testicle,  osteoma  of,  610 

papillomatous  adenocystoma  of,  609 

parasitic  cj^stic  tumors  of,  609 

retention  cysts  of,  609 

sarcoma  of,  609 

supernumerary,  599 

surgery  of,  621 

tumors  of,  608 

treatment,  630 
■founds  of,  treatment,  634 
Tests  for  permeability  of  kidney,  80 
Thiersch's    operation    for    epispadias, 

508 
Thompson's  searcher,  41 

urethral  forceps,  499 
Thorium,  preparation  of,  for  pyelog- 
raphy, 52 
Timothy  hay  bacilli  in  urine,  128 
Torsion  of  spermatic  cord,  607 

treatment,  607 
Transperitoneal  nephrectomj^  305 
Transplantation  of  ureter,  336 
Traumatism  of  female  urethra,  488 
treatment  of,  489 
of  lu-eter,  322 
Trendelenburg's  operation  for  hydro- 
nephrosis, 331 
Trichomonas  vaginalis  in  urine,  128 
Tube,  distal,  of  kidney,  153 
second,  of  kidne^',  153 
spiral,  of  kidney,  153 
Tubercle  bacillus  in  urine,  128 
antiformin  test  for,  241 
Tubercular  cystitis,  350 

cystoscopic  appearances  in,  66 
diagnosis  of,  361 
treatment  of,  362 
nephritis,  blood  in,  166,  167 
orchitis,  604 

medical  treatment  of,  616 
symptoms  of,  605 
Tuberculosis  of  kidney,  237 
course,  238 
diagnosis,  240 
embolic  or  descending  infection, 

238 
infection   by    ascending    inocula- 
tion, 238 
diagnosis  of,  240 
pathology,  237 
prognosis,  242 
treatment,  243 
of  ureter,  323 
Tubule,  collecting,  of  kidney,  153 
convoluted,  597 
irregular,  of  kidney,  153 
proximal  convoluted,  of  kidney,  153 
seminiferous,  597 
straight,  597 
urinary,  152 
Tumors,  benign,  of  testicle,  609 


ESIDEX 


663 


Tumors,  cystic,  of  testicle,  609 
fragments  of,  in  urine,  122 
in  bladder,  cystoscopic  appearances 

in,  68 
innocent,  of  bladder,  351 
of  female  urethra,  495 
treatment,  496 
malignant,  of  bladder,  352 
of  female  urethra,  494 

treatment,  495 
of  testicle,  610 
of  bladder,  350 
diagnosis,  388 
treatment,  388 
of  female  urethra,  494 
of  kidney,  277 
diagnosis,  283 
nephrectomy  in,  314 
treatment,  285 
of  penis,  499 
of  prostate,  587 
of  testicle,  608 

treatment  of,  630 
of  ureters,  321 

parasitic,  cystic,  of  testicle,  609 
Tunica  albuginea,  412,  596 
vaginalis,  596 
vasculosa,  596 
Tuttle's     operation     for     closure     of 

urethrorectal  fistula,  484 
Tyrosin  in  urine,  126 
Tyson's  glands,  414 


Ulcerations  of  penis,  500 
Ulcerative     cystitis,     non-tubercular, 

cystoscopic  appearances  in,  66 
Ultzmann's  catheter,  43 

syringe  for  instillation,  43 
Universal  cystoscopes,  63 
Urachus,  343 

patent,  410 
treatment,  411 

permeable,  344 
Urates  of  potassimn  in  urine,  125 

of  sodiiun  in  urine,  125 
Urea,  158 

in  urine,  114 
Uremia,  223 

blood  in,  168 

diagnosis  of,  231 

lesions  of  kidneys  in,  228 

prognosis  of,  235 

pulse  in,  232 

treatment  of,  234 

urine  in,  232 
Uremic  amaurosis,  177 

amblyopia,  177 
Ureter,  anastomosis  of,  lateral,  334 
Israel's  operation,  334 

anatomy  of,  320 


Ureter,  catheterization  of,  70 

tests     showing    permeability    of 

kidney  associated  with,  86 
with  reverse  cj'stoscope,  75 
with  ureteral  catheter  cystoscope 
of  straight  type,  72 
cysts  of,  321 
diseases  of,  321 

diagnosis  of,  325 
fistula  of,  324 
inflammation  of,  321 
kinks  of,  324 
malformations  of,  321 
pathologic  anatomj'  of,  321 
physiology  of,  320 
rectal  anastomosis  of,  327 
stone  in,  322 

operations  for,  341 
stricture  of,  322,  224 

Kiister's  operation  for,  331 
operations  for,  341 
surgery  of,  327 
transplantation  of,  336 
traumatism  of,  322 
tuberculosis  of,  323 
tumors  of,  321 
wounds  of,  325 

operations  for,  340 
Ureter-cystoscope,  Lewis',  71 
Ureterectomy,  341 
Ureteropyeloneostomy,  332 
Ureterotomy,  341 
Urethra,  anatomj-  of,  314 
calculi  in,  501 
diseases  of,  317 
female,  487 

anatomy  of,  487 
carcinoma  of,  494 
caruncles  of,  495 
condyloma  of,  495 
congenital  malformations  of,  488 
dilatation  of,  491 
treatment,  491 
examination  of,  489 
innocent  tumors  of,  495 

treatment,  496 
malignant  tumors  of,  494 

treatment,  495 
polypoid  fibroma  of,  496 
sarcoma  of,  495 
stricture  of,  490,  492 
diagnosis,  490 
treatment,  490 
traumatisms  of,  488 

treatment,  489 
tumors  of,  494 
foreign  bodies  in,  501 
membranous,  anatomy  of,  415 
penile  portion  of,  anatomy,  415 
prostatic,  anatomy  of,  414 
resection  of,  476 


664 


INDEX 


Urethra,  rupture  of,  472 
diagnosis,  473 
treatment,  473 
spongy  portion  of,  anatomy,  415 
stricture  of,  from  urethritis,  422 
location  of,  455 
symptoms  of,  454 
treatment  of,  455 
impassable,       from       urethritis, 
treatment,  459 
Urethral  discharge  in  examining,   20 
exudate,  examination  of,  128 

in  chronic  gonorrheal  urethritis, 

136 
in  cowperitis,  139 
in  gonorrheal  urethritis,  133 
in  prostatitis,  137 
in  simple  urethritis,  132 
in  vesiculitis,  138 
purulent,  129 
fistula  in  pendulous  tirethra,  opera- 
tion for,  479 
perineal,  operations  for,  480 
forceps,  Thompson's,  501 
instruments,  care  of,  90 
lubricants  for,  94 
sterilization  of,  91 
Urethritis,  417 

abortive  treatment  of,  428 

abscess    of    Littre's    glands    after, 

421 
acute  anterior,  course  of,  423 
symptoms  of,  423 
treatment  of,  433 
early  local,  436 
catarrhal,  417 
posterior,  symptoms  of,  424 

treatment  of,  434 
purulent,  418 
bacterial  content  in,  135 
bacteriology  of,  418 
chronic  anterior,  symptoms  of,  424 
treatment  of,  435 
catarrhal,  417 

diagnosis,  426 
posterior,  diagnosis,  427 
symptoms  of,  424 
treatment  of,  438 
urethral  exudate  in,  136 
complement-fixation  in,  144 
complications  of,  441 
diagnosis,  424 
epithelial  cells  in,  134 
German  method  of  abortive  treat- 
ment of,  429 
glass  test  for  locating  seat  of,  31,  425 
gonococcus  in,  134 
gonorrhea  of  eye  from,  442 
prognosis,  443 
symptoms,  443 
treatment,  443 


Urethritis,  gonorrhea  of  mouth  from, 
442 
of  rectum  from,  442 
gonorrheal,    bacterial    content    in, 
135 
chronic,  urethral  exudate  of,  136 
epithelial  cells  in,  134 
gonococcus  in,  134 
pus-cells  in,  134 
urethral  exudate  in,  133 
Greene  and  Brooks'  abortive  treat- 
ment of,  428 
impassable     stricture     of     urethra 

from,  treatment,  459 
in  female,  492 
treatment  of,  493 
KoUmann's    method    of    diagnosing, 
425       . 
mode  of  infection  in,  419 
pathologic  anatomy  of,  419 
pathology  of,  417 
pus-cells  in,  134 

retention    of    urine   from,    treat- 
ment, 459 
simple,    bacterial    content    in,    133 
epithelial  cells  in,  132 
urethral  exudate  in,  132 
stricture  of  meatus  urinarius  from, 

453 
of  urethra  from,  422,  454 
location,  455 
symptoms,  454 
treatment,  455 
symptoms  of,  422 
treatment  of,  resume,  440 
urethral  exudate  in,  133 
Young's  method  of  diagnosing,  425 
Urethrocystoscope,    Goldsmith's   irri- 
gation, 60 
Urethrometer,  39 

Otis,  39,  40 
Urethrorectal  fistula,  diagnosis  of,  482 
operations  for,  481 
prognosis  of,  482 
treatment  of,  482 
local,  483 
operative,  484 
palliative,  483 
Tuttle's  operation  for  closure  of, 
484 
Urethrorectoperineal   fistula,    diagno- 
sis of,  482 
operations  for,  481 
prognosis  of,  482 
treatment  of,  482 
local,  483 
operative,  484 
palliative,  483 
Urethrotome,  Maisonneuve's,  464 

Otis,  465 
Urethrotomy,  470 


INDEX 


665 


Urethrotomy,  external,  466 

without  a  guide,  470 
internal,  463 
Uric  acid,  115,  158 

infarction,  271 
Urinary  constituents,  114 

excretion,    diminished    amount    of, 

in  exatnuiing,  2 1 
fever,  27 
sediment,  130 
stream,  caliber  of,  21 
tubule,  152 
Urine,  156 

acetone  in,  118 
acid  reaction  of,  157 

substances  in,  125 
actinomyces  fungi  in,  128 
albumin  in,  116 
alkaline  substances  in,  127 
ammonio-magnesium  •  phosphate  in, 

127 
ammonium  urate  in,  127 
amorphous  phosphates  in,  126 
amount  passed,  113 
amyloid  casts  in,  124 
bacteria  in,  127 

as  cause  of  suppurative  nephritis, 

bile-pigments  in,  119 

blood-casts  in,  124 

calcium  carbonate  in,  127 
oxalate  crystals  in,  126 

casts  in,  123 

cercomonas  intestinalis  in,  128 

chemic  composition  of,  157 

chlorids  of,  115 

cloudy,  31 

collection  of  specimen  of,  for  exami- 
nation, 112 

colon  bacillus  in,  128 

color  of,  157 

conjugate  sulphates  in,  116 

constituents  of,  114 

crystalline  deposits  in,  125 

cylindroids  in,  123 

cystin  in,  126 

decrease  in  amount  of,  113 

echinococcus-hooklets  in,  128 

epithelial  casts  in,  124 

epithelium  in,  121 

erythrocytes  in,  120 

examination  of,  112 

fat  in,  119 

fatty  casts  in,  124 

filaria  sanguinis  hominis  in,  128 

fragments  of  tumors  in,  126 

gonococcus  in,  127 

granular  casts  in,  124 

hyaline  casts  in,  124 

in  tuemia,  232 

incontinence  of,  in  children,  347 


Urine,  incontinence  of,  in  examining 

patient,  23 
indican  in,  119 
leucin  in,  126 
leukocytes  in,  121 
microscopic  examination  of,  119 
mucus  in,  121 
organized  deposits  in,  120 
phosphorus  in,  116 
preformed  sulphates  in,  116 
pro  tens  bacillus  in,  128 
pus-casts  in,  124 
pus-cells  in,  121 
reaction  of,  114 
red  blood-corpuscles  in,  120 
retention  of,  after  operation,  108 

from  urethritis,  treatment,  459 

in  examining,  23 

operations  for,  330 
sediment  in,  120 
separation  of,  79 
smegma  bacillus  in,  128 
specific  gravity  of,  113,  157 
spermatozoa  in,  123 
staphylococcus  in,  127 
streptococcus  in,  127 
sugar  in,  117 
sulphur  in,  116 
timothy  hay  bacillus  in,  128 
trichomonas  vaginalis  in,  128 
tubercle  bacillus  in,  128 

antiformin  test  for,  241 
tyrosin  in,  126 
urates  of  potassium  in,  125 

of  sodium  in,  125 
urea  in,  114 
uric  acid  in,  1 1 5 
waxy  casts  in,  114 
Urorrhea,  142 
Uterus  masculinus,  532 

Vaccine   treatment,    gonococcus,    of 
gonorrheal  rheumatism  and  epididy- 
mitis, 451 
Vagina,  examination  of,  30 
Vaginal  secretion,  examination  of,  143 
Valentine's  endoscope,  57 

irrigating  outfit,  436 
Varicocele,  610 

treatment  of,  635 
Vas  deferens,  599 

irrigation  and  drainage  of  semi- 
nal duct  and  vesicle  through, 
637 
Vasa  efferentia,  598 
Verumontanum,  415 
Vesicles,  seminal,  522 
diseases  of,  522 

treatment,  523 
Fuller's  incision  for  removal  of, 
526,  528 


666 


IN^EX 


Vesicles,  seminal,  irrigation  and  drain- 
age of,  through  vas  deferens,  404 
Kocher's  incision  for  removal  of, 

525,  527  ,     ^ 
Kxaske's  incision  for  removal  of, 

524.  527 
Rydygier's       modification 
of,  524,  527 
Senn's   incision   for   removal    of, 

526,  527 

von  Dittel's  incision  for  removal 

of,  525,  527 
Zuckerkandl's     incision    for     re- 
moval of,  525,  527 
Vesicuhtis,  523 
treatment  of,  523 
m^ethral  exudate  in,  138 
Voelcher  and  Joseph's  indigo-carmin 

test,  87 
von  Dittel's  incision  for  removal  of 
seminal  vesicles,  521,  527 

Water  test  for  permeability  of  kidney 
associated  with  ureter  catheteriza- 
tion, 86 


Waxy  casts  in  urine,  124 
Wheelhouse's  staff,  470 
Wounds    of    bladder,     diagnosis    of, 
404 
treatment  of,  405 
of  kidnej-,  261 
prognosis,  261 
treatment,  262 
of  penis,  497 

treatment,  497 
of  prostate,  534 
of  testicle,  treatment  of,  634 
of  tu-eter,  324 

operations  for,  340 


X-RAY,  value  of,  in  diagnosis,  51 


Young's      method      of      diagnosing 
urethritis,  425 


Zuckerkandl's  incision  for  removal 
of  seminal  vesicles,  525,  527 


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Cabot's  Works  on  Diagnosis 

Differential  Diagnosis.  Presented  through  an  Analysis  of  Cases. 
By  Richard  C.  Cabot,  M.  D.,  Assistant  Professor  of  Chnical  Medi- 
cine, Harvard  Medical  School,  Boston.  Each  volume  an  octavo  of 
about  750  pages,  illustrated.  Per  volume:  Cloth,  $^.'^0  net. 

Dr.  Cabot's  work  takes  up  diagnosis  from  the  point  of  view  oi  \h& presentittg 
symptom — the  symptom  in  any  disease  which  holds  the  foreground  in  the  chnical 
picture  :  the  principal  complaint.  It  groups  diseases  under  these  symptoms,  and 
points  the  way  to  proper  reasoning  in  coming  to  a  correct  diagnosis.  It  works 
backward  from  each  leading  symptom  to  the  actual  organic  cause  of  the  symptom. 
This  the  author  does  by  means  of  case-teaching. 

The  symptom-gfoups  considered  in  Volume  I  [New  (3d)  Edition]  are  :  Headache,  gen- 
eral abdominal  pain,  epigastric  pain,  right  hypochondriac  pain,  left  hypochondriac  pain,  right 
iliac  pain,  left  iliac  pain,  axillary  pain,  pain  in  arms,  pain  in  legs  and  feet,  fevers,  chills, 
coma,  convulsions,  weakness,  cough,  vomiting,  hematuria,  dyspnea,  jaundice,  and  nervous- 
ness— 21  symptoms  and  385  cases. 

Volume  II  (Just  Out)  :  Abdominal  and  other  tumors,  vertigo,  diarrhea,  dyspepsia, 
hematemesis,  enlarged  glands,  blood  in  stools,  swelling  of  face,  hemoptysis,  edema  of  legs, 
frequent  micturition  and  polyuria,  fainting,  hoarseness,  pallor,  swelling  of  arm,  delirium,  pal- 
pitation and  arhythmia,  tremor,  ascites  and  abdominal  enlargement — a  total  of  19  symptoms 
and  317  instructive  cases. 


Morrow's  Diagnostic  and 
Therapeutic  Technic 

Diagnostic  and  Therapeutic  Technic.  By  Albert  S.  Morrow, 
M.  D.,  Clinical  Professor  of  Surgery,  New  York  Polyclinic.  Octavo 
of  834  pages,  with  860  original  line  drawings.  Cloth,  ^5.00  net. 

NEW  (2d)  EDITION 

Dr.  Morrow's  new  work  is  decidedly  a  work  for  you — the  physician  engaged 
in  general  practice.  It  is  a  work  you  need  because  it  tells  you  just  how  to  perform 
those  procedures  required  of  you  every  day,  and  it  tells  you  and  shows  you  by 
clear,  new  line-drawings,  in  a  way  never  before  approached.  It  is  not  a  book  on 
drug  therapy  ;  it  deals  alone  with  physical  or  mechanical  diagnostic  and  thera- 
peutic measures.  The  information  it  gives  is  such  as  you  need  to  know  every 
day — transfusion  and  infusion,  hypodermic  medication,  Bier's  hyperemia,  explora- 
tory punctures,  aspirations,  anesthesia,  etc.  Then  follow  descriptions  of  those 
measures  employed  in  the  diagnosis  and  treatment  of  diseases  of  special  regions  or 
organs:  proctoclysis,  cystoscopy,  etc. 
Journal  American  Medical  Association 

"  The  procedures  described  are  those  which  practitioners  may  at  some  time  be  called 
on  to  perform.'' 


SAUNDERS'    BOOKS   ON 


Musser  and  Kelly  on 
Treatment 

A  Handbook  of  Practical  Treatment.  By  82  eminent  specialists. 
Edited  by  John  H.  Musser,  M.  D.,  and  A.  O.  J.  Kelly,  M.  D.,  Univer- 
sity of  Pennsylvania.  Three  octavos  of  950  pages  each,  illustrated. 
Per  volume:  Cloth,  ^6.00  net;  Half  Morocco,  $7.S0  net.  Subscrip- 
tion. 

IN  THREE  VOLUMES 
A  PRACTICE  FOR  QUICK  REFERENCE  AND  DAILY  USE 

Every  chapter  in  this  work  was  written  by  a  speciahst  of  unquestioned  authority. 
Not  only  is  drug  therapy  given  but  also  dietotherapy,  serumtherapy,  organo- 
therapy, rest-cure,  exercise  and  massage,  hydrotherapy,  climatology,  electro- 
therapy, ;r-ray,  and  radial  activity  are  fully,  clearly,  and  definitely  discussed. 
Those  measures  partaking  of  a  surgical  nature  have  been  presented  by  surgeons. 

The  Medical  Record 

"  The  most  modern  and  advanced  views  are  presented.  It  is  difficult  to  pick  out  any  one 
topic  that  deserves  special  commendation,  all  parts  fully  covering  their  particular  field,  and 
written  with  that  fulness  of  detail  demanded  by  the  every-day  needs  of  the  practitioner." 


Thomson's   Clinical   Medicine 

Clinical  Medicine.     By  William  Hanna  Thomson,  M.  D.,  LL.  D., 

formerly  Professor  of  the  Practice  of  Medicine  and  of  Diseases  of  the 

Nervous  System,  New  York   University  Medical  College.     Octavo  of 

675  pages.  Cloth,  ^5.00  net;  Half  Morocco,  $^.^0  net. 

TWO  PRINTINGS  IN  FOUR  MONTHS 

This  new  work  represents  over  a  half  century  of  active  practice  and  teach- 
ing. It  deals  with  bedside  medicine — the  applicatiofi  of  medical  knowledge  for 
the  relief  of  the  sick.  First  the  meaning  of  common  and  important  symptoms  is 
stated  definitely ;  then  follows  a  chapter  on  the  use  of  remedies  and  a  classifi- 
cation of  them  ;  next  the  section  on  infections,  and  last  a  section  on  diseases  of  par- 
ticular organs  and  tissues.  It  is  medical  knowledge  applied — from  cover  to  cover. 
An  important  chapter  is  that  on  the  mechanism  of  surface  chill  and  "catching 
cold, ' '  going  very  clearly  into  the  etiologic  factors,  and  outlining  the  treatment. 
The  chapter  on  remedies  takes  up  non-medicinal  and  medicinal  remedies  and 
vaccine  and  serum  therapy.  In  the  chapter  on  the  ductless  glands  the  subject  of 
internal  secretions  is  verj^  clearly  presented,  giving  you  the  latest  advances.  The 
infectious  diseases  are  taken  up  in  Part  II,  while  Part  III  deals  with  diseases  of 
special  organs  or  tissues,  every  disease  being  fully  presented  from  the  clinical 
side.     Treatment,  naturally,  is  very  full. 


PRACTICE    OF  MEDICINE 


Ward's  Bedside  Hematology 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.D.,  Fellow  oi  the 
Royal  Society  of  Medicine,  London,  England.  Octavo  of  394  pages, 
illustrated.  Cloth,  ^3.50  net. 

INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  gives  you  the  exact  technic  for  obtaining  the  blood  for  ex- 
amination, the  making  of  smears,  the  blood-count,  finding  coagulation  time,  etc. 
Then  it  takes  up  each  disease,  giving  you  the  synonyms,  definition,  nature,  gen- 
eral pathology,  etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (dis- 
cussing each  symptom  in  detail),  course  of  the  disease,  clinical  varieties,  compli- 
cations, diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums,  etc.Y 

Faught*s  Blood-Pressure 

Blood = Pressure  from  the  Clinical  Standpoint.  By  Francis  A. 
Faught,  M.  D.,  formerly  Instructor  in  Medicine,  Medico-Chirurgical 
College  of  Philadelphia.  Octavo  of475  pages,  illustrated.  Cloth,  ^3.25  net. 

JUST  OUT— NEW  (2d)  EDITION 

Dr.  Faught' s  book  is  designed  for  practical  help  at  the  bedside.  Besides  the 
actual  technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The  practical 
application  of  sphygmomanometric  findings  within  recent  years  make  it  imperative 
for  every  medical  man  to  have  close  at  hand  an  up-to-date  work  on  this  subject. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.     By   G.    Carroll   Smith,  M.D.,  Boston. 

l2mo  of  377  pages.     Cloth,  $2.50  net. 

NEW  (2d)   EDITION 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
of  a  general  nature,  which  will  appeal  to  the  general  practitioner." 


SAUNDERS'   BOOKS    ON 


Kolmer's  Specific  Therapy 

Infection,  Immunity,  and  Specific  Therapy.  By  John  A.  Kolmer, 
M.  D.,  Dr.  p.  H.,  Assistant  Professor  of  Experimental  Pathology,  Uni- 
versity of  Pennsylvania.  Octavo  of  900  pages,  with  143  original  illus- 
trations, 43  in  colors,  drawn  by  Erwin  F.  Faber.  Cloth,  ^6.00  net; 
Half  Morocco,  ^7.50  net. 

ORIGINAL  ILLUSTRATIONS 

Dr.  Kolmer's  book  gives  you  a  full  account  of  infection  and  immunity,  and 
the  application  of  this  knowledge  in  the  specific  diagnosis,  prevention,  and  treat- 
ment of  disease.  The  section  devoted  to  immunologic  technic  gives  you  every  de- 
tail, from  the  care  of  the  centrifuge  and  making  a  simple  pipet  to  the  actual  pro- 
duction of  serums  and  vaccines.  Under  specific  therapy  you  get  methods  of 
making  atitogeftoiis  vaccines  and  their  actual  use  in  diagnosis  and  treatment.  The 
directions  for  injecting  vaccines,  serums,  salvarsan,  etc. — with  the  exact  dosage — 
are  here  given  so  clearly  that  you  will  be  able  to  use  these  means  of  treatment  in 
your  daily  practice.  You  also  get  full  directions  for  making  the  clinical  diagnostic 
reactions — the  various  tuberculin  tests,  luetin,  mallein,  and  similar  reactions,  all  illus- 
trated with  colored  plates.     The  final  section  is  devoted  to  laboratory  experiments. 


Anders  £^  Boston's  Medical  Diagnosis 


A  Text=Book  of  Medical  Diagnosis.  By  James  M.  Anders,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  Medicine,  and  L.  Napoleon  Boston,  M.  D., 
Professor  of  Physical  Diagnosis,  University  of  Pennsylvania.  Octavo 
of  1248  pages,  with  466  illustrations,  a  number  in  colors.  Cloth,  $6.00 
net;  Half  Morocco,  $7.50  net. 

NEW  (2d)  EDITION 

This  new  edition  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory- 
worker  is  most  fortunate.     It  must  long  occupy  a  pre-eminent  position." 


THE  PRACTICE   OF  MEDICINE 


Anders' 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Medicine,  University  of  Pennsylvania. 
Handsome  octavo,  1336  pages,  fully  illustrated.  Cloth,  I5. 50  net;  Half 
Morocco,  $7.00  net. 

THE  NEW  (I2th)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D., 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago, 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical  Diagnosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
Professor  of  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  589  pages,  with  243  original  illustrations.  Cloth,  $3.50  net 

NEW  (3d)  EDITION 

Dr.  DaCosta' s  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 

Dr.  Henry  L.   Eisner,   Professor  of  Medicine  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.     In  every  way  I  find  it  a  superior  production." 


SAUNDERS'  BOOKS  ON 


Sahli*s  Diagnostic  Methods 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof. 
Dr.  H,  Sahli,  of  Bern.  Edited,  with  additions,  by  Nath'l  Bowditch 
Potter,  M.  D.,  Professor  of  Clinical  Medicine,  Columbia  University 
(College  of  Physicians  and  Surgeons),  New  York.  Octavo  of  1229 
pages,  illustrated.     Cloth,  $6.50  net ;  Half  Morocco,  |8.oo  net. 

THE  NEW  (2d)  EDITION,  ENLARGED  AND  RESET 

Dr.  Sahli' s  great  work  is  a  practical  diagnosis,  written  and  edited  by  practical 
clinicians.  So  thorough  has  been  the  revision  for  this  edition  that  it  was  found 
necessary  practically  to  reset  the  entire  work.  Every  line  has  received  careful 
scrutiny,  adding  new  matter,  eliminating  the  old. 

Lewellys  P.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 

Friedenwald  and  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.     Octavo  of  857  pages.  Cloth,  ;^4.oo  net. 

THE  NEW  (4th)  EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  exhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  aiid  of  Clinical  Medicine,    Tulane   University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available, 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists 

Diet  Lists  of  the  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.  Cloth,  ^ 1. 00  net. 

Here  Dr.  Carter  has  compiled  all  the  diet  lists  for  the  various  diseases  and  for  conva- 
lescence as  prescribed  at  the  Presbyterian  Hospital.      Recipes  are  also  included. 


PRACTICE    OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  Robert 
Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  CHnical  Medicine.  Octavo  of  1021  pages,  with 
388  illustrations.     Cloth,  ;$6. 50  net ;  Half  Morocco,  ;^8.oo  net. 

NEW  (2d)  EDITION 

The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colon  Bacillus  Infection  and  on  Diseases  of  the  Pancreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  Intes- 
tinal Complications  of  Typhoid  Fever  and  on  Diverticulitis. 

The  Therapeutic  Gazette 

"  The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examination  are  adequately  and  correctly  described." 


Gant  on  Diarrheas 

Diarrheal,  Inflammatory,  Obstructive,  and  Parasitic  Diseases  of 
the  Qa;3tro=intestinal  Tract.     By  Samuel   G.  Gant,   M.  D.,  LL.D., 

Professor  of  Diseases  of  Sigmoid  Flexure,  Colon,  Rectum,  and  Anus, 
New  York  Post-graduate  Medical  School  and  Hospital.  Octavo  of  604 
pages,  181  illustrations.     Cloth,  ^^6.00  net;  Half  Morocco,  ^7.50  net, 

ILLUSTRATED 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic  points  are 
given  under  each  disease,  a  fuller  description  of  diagnostic  methods  is  given  in  a 
special  chapter.  The  differential  diagnosis  of  diarrheas  of  local  and  those  of  sys- 
temic disturbances  is  strongly  brought  out.  There  is  a  special  chapter  on  ner- 
vous diarrheas  and  those  originating  from  gastrogenic  and  enterogenic  dyspepsias. 
You  get  methods  of  simultaneously  controlling  associated  constipation  and  diar- 
rhea. You  get  a  complete  formulary.  The  limitations  of  drugs  are  pointed  out, 
and  the  indications  and  technic  of  all  surgical  procedures  given. 

Gant  on  Constipation  and  Obstruction 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  latter  really 
being  a  complete  work  on  rectocolonic  surgery. 

Octavo  of  575  pages,  with  250  illustrations.     By  SAMUEL  G.  Gant,  M.  D.     Cloth,  $6.00  net. 


SAUA-DERS'    BOOKS   ON 


NOTHNAGEL'S    PRACTICE 

Edited  by  ALFRED   STENGEL,  M.  D. 
Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmann.  Edited,  with  additions,  by  William  Osler,  M,  D., 
F.  R.  C.  P.,  Oxford,  England.     Octavo  of  646  pages,  illustrated. 

Smallpox,  Varicella,  Cholera,  Erysipelas,  Pertussis,  Hay  Fever 

By  Dr.  H.  Lmmermann,  Dr.  Th.  von  Jurgensen,  Dr.  C.  Liebermeister, 
Dr.  H.  Lenhartz,  and  Dr.  G.  Sticker.  Edited,  with  additions,  by  Sir 
J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Ireland.    Octavoof  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.  ,  and  Dr.  Th.  von  Jurgensen.  Edited, 
with  additions,  by  William  P.  Northrup,  M.  D.,  New  York.  Octavo  of 
672  pages,  illustrated. 

Bronchi,  Pleura,  and  Inflammations  of  the  Lungs 

By  Dr.  F.  A.  Hoffmann,  Dr.  O.  Rosenbach,  and  Dr.  F.  Aufrecht. 
Edited,  with  additions,  by  John  H.  Musser,  M.  D.      Octavo  of  1029  pages. 

Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  Dr.  E.  Neusser,  and  Drs.  H.  Quincke  and  G.  Hoppe- 
Seyler.  Edited,  with  additions,  by  Reginald  H.  Fitz,  M.  D.,  Boston; 
and  Fred.  A.  Packard,  M.  D.,  Phila.     Octavo  of  918  pages,  illustrated. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D.,  Buffalo.      Octavo  of  835  pages. 

Diseases  of  the  Intestines  and  Peritoneum  Second  edition 

By  Dr.  Hermann  Nothnagel.  Edited,  with  additions,  by  H.  D.  Rolles- 
ton,  M.  D.,  F.  R.  C.  p.,  London.     Octavo  of  iioo  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet.  Edited,  with  additions,  by  Walter  B.  James,  M.D., 
New  York.     Octavo  of  806  pages. 

Diseases  of  the  Blood 

By  Dr.  P.  Ehrlich,  Dr.  A.  Lazarus,  Dr.  K.  von  Noorden,  and  Dr. 
Felix  Pinkus.  Edited,  with  additions,  by  Alfred  Stengel,  M.  D.,  Phila- 
delphia.    Octavo  of  714  pages,  illustrated. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg  and  Dr.  O.  Leichtenstern.  Edited,  with  additions, 
by  Ronald  Ross,  F.  R.  C.  S,  ;  J.  W.  W.  Stephens,  M.  D.;  and  Albert 
S.  Grunbaum,  F.  R.  C.  p.,  Liverpool.      Octavo  of  769  pages,  illustrated. 

Kidneys,  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator  and  Dr.  M.  Litten.  Edited,  with  additions,  by  James 
B.  Herrick,  M.  D.,  Chicago.     Octavo  of  815  pages,  illustrated. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgensen,  Prof.  Dr.  L.  Krehl,  and  Prof.  Dr. 
L.  von  Schrotter.  Edited  by  George  Dock,  M.  D.,  New  Orleans.  Octavo 
of  848  pages,  illustrated. 

SOLD  SEPARATELY-PER   VOLUME.    CLOTH,  $5.00  NET;   HALF  MOROCCO,  $6.00  NET 


THERAPEUTICS  AND   EXERCISE  ii 

Bastedo's   Materia   Medica 

Pharmacology,    Therapeutics,    Prescription    Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  Bastedo,  Ph.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.  Octavo 
of  602  pages,  illustrated.  Cloth,  ^3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  of  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  elimination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medicsd  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacologic. 
The  text  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  Tait  McKenzie,  B.  A.^ 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  585  pages,  with  478  original 
illustrations.  Cloth,  ^4.00  net. 

D.  A.  Seurgeant,   M.   D.,  Director  of  Hemenway  Gymnasium,  Harvard  Uni'^ersity. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Bonney's  Tuberculosis  second  Edition 

Tuberculosis.  By  Sherman  G.  Bonney,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages,  with 
243  illustrations.      Cloth,  ^7.00  net;  Half  Morocco,  ^8.50  net. 

Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published." 


12  SAUNDERS'    BOOKS   ON 

Stevens*  Therapeutics  New  (sth)  Edition 

A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  ^3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  pubhshed.  In  this  new  edition  the  work  has  undergone,  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  New  (6th)  cdHion 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  ^4.00  net;  Half  Morocco,  $5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  -has  been  eliminated,  and 
special  attention  has  been  given  to  the  toxicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 

Sollmann's  Pharmacolo|»y  New  (2d)  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  ^4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of 
the  nature  and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate 
relation  between  pharmacology  and  practical  medicine. 

Slade's  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy.  By  Charles  B. 
Slade,  M.  D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital  Medical   College.     Cloth,  $1.25  net. 

"  The  fundamental  methods  and  principles  of  physical  examination,  well  illustrated,  largely  by  line 
drawings.     The  book  is  to  be  strongly  recommended." — Boston  Medical  and  Surgical  Journal. 

Amy's  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  G.,  Ph.  D., 
Professor  of  Chemistry,  New  York  College  of  Pharmacy.  Octavo  of 
1 1 75  pages,  with  246  illustrations.     Cloth,  ^5.00  net. 


THERAPEUTICS  AND  MATERIA   MEDICA  13 

Tousey's  Medical  Electricity 
Ront^en  Rays,  and  Radium 

Medical  Electricity,  Rdntgen  Rays,  and  Radium.  By  Sinclair 
TousEY,  M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hospital, 
New  York.  Octavo  of  1219  pages,  with  801  illustrations,  ig  in  colors. 
Cloth,  I7.50  net;  Half  Morocco,  ^9.00  net. 

NEW  (2d)  EDITION.  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased  the  size 
of  the  book  by  some  100  pages.  About  50  new  illustrations  have  been  added.  The  new 
matter  added  includes :  Diathermy,  sinusoidal  currents,  radiography  with  intensifying 
screens,  rontgenotherapy,  the  Coolidge  and  similar  Rontgen  tubes  and  the  author's  method 
of  dosage,  and  radium  therapy  are  noted.  The  book  has  been  enriched  by  including  several 
of  Machado's  tabular  classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  x-rays,  and  radium  in 
medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing  is  omitted.  It  tells  you 
how  to  equip  your  office,  and,  more  than  that,  how  to  use  your  apparatus,  explaining  away 
all  difficulties.  It  tells  you  just  how  to  apply  these  measures  in  the  treatment  of  disease. 
The  chapters  on  dental  radiography  are  particularly  valuable  to  those  interested  in  dental 
work. 


Deaderick  &  Thompson's  Endemic 
Diseases  of  South 

Endemic  Diseases  of  the  Southern  States.  By  William  H. 
Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine  ; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Association 
of  Immunologists.  Octavo  of  546  pages,  illustrated.  Cloth,  ;^5.00 
net;  Half  Morocco,  $(y.'^o  net. 

JUST  ISSUED 

This  work  records  the  experiences  of  two  active  practitioners  and  teachers 
right  in  the  field  and  thoroughly  familiar  with  these  diseases.  Those  diseases  of 
special  importance  are  given  unusual  consideration.  Pellagra,  for  instance,  is 
given  eight  chapters  for  its  full  consideration,  while  hookworm  disease  covers  nine 
chapters  and  malaria  eight.  You  get  the  etiology,  pathology,  clinical  historj', 
diagnosis,  prognosis,  prophylaxis,  and  treatment  of  each  disease,  presented  from 
every  angle,  always  bearing  in  mind  the  practical  aim  of  the  work — the  application 
of  the  knowledge  in  daily  practice. 


14  SAUNDERS*    BOOKS   ON 

GET  A  •  THE  NEW 

THE  BEST  /\  111  6  f  1  C  Si  H  STANDARD 

Illustrated    Dictionary 


New  (8th)  Edition— 1500  New  Words 

The  American  Illustrated  Medical  Dictionary. — By  W.  A.  New- 
man Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Dic- 
tionary." Large  octavo  of  1 1 37  pages,  bound  in  full  flexible  leather. 
Price,  $4..$o  net;  with  thumb  index,  ^5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

HowtO'd  A.  l^eWyttA.H., Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose=Book.  New  (4th)  Edition 

Dose-Book  and  Manual  of  Prescription-Writing.  ByE.  Q.  Thornton,  M.D., 
Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
octavo,  410  pages,  illustrated.     Flexible  leather,  $2.00  net. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  M..V>.,  Professor  of  Pharmacology,  Northwestern  University  Medi- 
cal School. 

Lusk   on    Nutrition  New  (2d)  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D.,  Professor 
of  Physiology  in  Cornell  University  Medical  School.  Octavo  of  402  pages.  Cloth, 
^3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 
— Lewellys  F.  Barker,  M.  "D.,  Johns  Hopkins  University. 

Camac's  "Epoch-making  Contributions" 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  by  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  ^4.00  net. 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors."— 
Therapeutic  Gazette. 


PRACTICE,    MATERIA   MEDIC  A,   Etc.  IJ 

The  American  Pocket  Medical  Dictionary  New  (9th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor. 
LAND,  M.  D.,  Editor  "  American  Illustrated  Medical  Dictionary."  693  pages.  Flexible 
leather,  with  gold  edges,  ^1.25  net;  with  thumb  index,  %\.yi  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Therapeutics  and 
Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D,,  Professor  of  Dermatology  in 
the  University  of  Illinois ;  and  Eugene  W.  Caldwell,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  pages,  with  200  illustrations.  Cloth,  ^5.00  net; 
Half  Morocco,  $6.50  net. 

Cohen   and   Eshner's   Diag>nOSis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  ;^I. 00  net.     In  Saunders'  Question- ConiJ>end  Series. 

Morris'  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  1 2mo,  300 pages.  Cloth,  ^l.oo  net.  In  Saunders' 
Question-  Compend  Series. 

Kelly's  Cyclopedia  of  American  Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  Howard  A.  Kelly,  M.  D., 
Johns  Hopkins  University.  Two  octavos  of  525  pages  each,  with  portraits.  Per  set: 
Cloth,  ^10.00  net;   Half  Morocco,  ;?i3.oo  net. 

Todd's  Clinical  Diagnosis  The  New  (3d)  Edition 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell  Todd,  M.D.,  Professor 
of  Pathology,  University  of  Colorado.  l2mo  of  585  pages,  with  164  text-illustrations 
and  10  colored  plates.     Cloth,  $2.50  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.,  Emeritus  Professor  of  Medicine 
in  Rush  Medical  College.     i2mo  of  302  pages,  illustrated.    Cloth,  ^1.50  net. 

Oertel  on  Bright' s  Disease  illustrated 

The  Anatomic  Histological  Processes  of  Bright's  Disease.  By  Horst 
Oertel,  M.  D.,  Director  of  the  Russell  Sage  Institute  of  Pathology,  New  York.  Octavo 
of  227  pages,  with  44  text-cuts  and  6  colored  plates.     Cloth,  $5.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D.,  Dean  of  Harvard 
Graduate  Medical  School,  Boston.  Single  charts,  5  cents;  50  charts,  ^2.00  net ;  500 
charts,  $18.00  net;    looo  charts,  $30.00  net. 

Eggleston's  Prescription  Writing 

essentials  of  prescription  Writing.  By  Gary  Eggleston,  M.  D.  Instructor 
in  Pharmacology,  Cornell  University  Medical  School.  i6mo  of  125  pages.  Cloth,  $1.00 
net. 


1 6  SAUNDERS'    BOOKS    ON  PRACTICE,   Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr. 
Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  ^3.00  net.  In  Saunders' 
Hand- Atlas  Series. 

Abbott's  Medical  Electricity 

Medical  Electricity.  By  George  Knapp  Abbott,  M.  D.,  Dean  and  Pro- 
fessor of  Physiologic  Therapy  and  Practice,  College  of  Medical  Evangelists,  Loma  Linda, 
California.      i2mo  of  132  pages,  illustrated.     Cloth,  ^1.25  net. 

Stevens*  Practice  of  Medicine  New  (loth)  Edition 

A  Manual  of  the  Practice  of  Medicine.     By  A.  A.  Stevens,  A.  M.,  M.  D., 

Professor  of   Pathology,   Woman's   Medical   College,    Phila.  Specially  intended  for 

students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  629  pages, 
illustrated.     Flexible  leather,  ^2.50  net. 

Saunders'  Pocket  Formulary  New  (9th)  Edition 

Saunders'  Pocket  Medical  Formulary.  By  W^illiam  M.  Powell,  M.  D. 
Containing  1831  formulas  from  the  best-known  authorities.  With  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  flap,  ^1-75  net. 

De&derick  on  Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick,  M.  D.,  Member 
American  Society  of  Tropical  Medicine;  Fellow  London  Society  of  Tropical  Medicine 
and  Hygiene.  Octavo  of  402  pages,  illustrated.  Cloth,  $^.^0  net;  Half  Morocco,. 
;^6.oo  net. 

Niles  on  Pellagra  New  (2d)  Edition 

Pellagra.       By    George    M.   Niles,   M.  D.,   Gastro-enterologist  to  the  Georgia 
Baptist  Hospital,  Atlanta.     Octavo  of  225  pages,  illustrated.     Cloth,  ;53.oo  net. 

Hinsdale's  Hydrotherapy 

Hydrotherapy.  By  Guy  Hinsdale,  M.  D.,  Fellow  Royal  Society  of  Medicine 
of  Great  Britain.      Octavo  of  466  pages,  illustrated.     Cloth,  $3.50  net. 

Swan's  Prescription-writing  and  Formulary 

Prescription-writing  and  Formulary.  By  John  M.  Swan,  M.  D.,  formerly 
Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  i6mo  of  185  pages.  Flexible 
leather,  ^1.25  net. 

Stewart's  Pocket  Therapeutics  and  Dose-book      E^Jon 

Pocket  Therapeutics  and  Dose-Book.  By  Morse  Stewart,  Jr.,  M.  D.  32mo 
of  263  pages.     Cloth,  ^i.oo  net. 


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